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Social needs of older people: a systematic literature review.

Published online by Cambridge University Press:  03 April 2017

Social needs are important basic human needs. When social needs are not satisfied, this can lead to mental and physical health problems. With a growing population of older adults and the need for them to stay healthy and community-dwelling, satisfying social needs is important. The aim of this review is to give more insight into the social needs of older people and subsequently into the characteristics of effective interventions for satisfying older people's social needs. A systematic review of the existing literature on quantitative, qualitative and mixed empirical studies on the social needs of older people was conducted. The themes that emerged were diversity, proximity, meaning of the relationship and reciprocity. These themes offered several intervention implications. Participation in hobbies and in volunteer work and being connected were among the main findings. The social needs of older people are diverse. They focus on both the intimate and the peripheral members of their networks. When satisfying social needs, reciprocity is important. The feeling of connectedness to others and to a community or neighbourhood contributes to wellbeing as well as a feeling of independence. Staying active by doing volunteer work or participating in (leisure) social activities satisfies social needs. Therefore, interventions should focus especially on the connectedness, participation and independence of the older adult.

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• Volume 38, Issue 9
• TINA TEN BRUGGENCATE (a1) (a2) , KATRIEN G. LUIJKX (a1) and JANIENKE STURM (a2)
• DOI: https://doi.org/10.1017/S0144686X17000150

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• Academic Literature Review
• Open access
• Published: 13 November 2013

Physical consequences of falls in the elderly: a literature review from 1995 to 2010

• Miguel Terroso 1 , 2 ,
• Natacha Rosa 2 ,
• Antonio Torres Marques 2 &
• Ricardo Simoes 1 , 3 , 4  

European Review of Aging and Physical Activity volume  11 ,  pages 51–59 ( 2014 ) Cite this article

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In the last decade, population ageing has been registered as a global phenomenon. A relation exists between falling and ageing, since falling frequency increases significantly with age. In fact, one in three older adult falls annually. Although ageing is generically associated with decrease and degeneration of psychological and physical functions, it is still not common for the correct identification of risk factors to lead to a clinical prognosis of the elder being in risk of falling. Therefore, the goal of this review article is to identify, categorise and analyse typical ageing and fall factors mentioned in the literature as well as to quantify the number of times they were referenced. The research considered hundreds of publications, but analysis was then restricted to the 87 most pertinent articles written in English and published in journals or scientific magazines between 1995 and 2010. We concluded that falls among older adults can be characterised by the following: anatomic characteristics and physiological consequences of ageing; the pathologies that induce falls, which can be neurological, musculoskeletal, cardiovascular and other diseases; causes and risk factors of falls that can be behavioural, biological, environmental or socio-economic; type of physical consequences of falls, including fractures, bruises, injuries or other physical consequences; and strategies to prevent, mitigate or rehabilitate, which can be of a physical, environmental or behavioural nature.

Introduction

Elderly are currently considered the fastest growing age group worldwide [ 13 ]. In the last decades, the number of elderly people in the world has been consistently and proportionally increasing. In 1996, there were a total of 323 million people in the world aged above 65 years [ 49 ]. That number increased in 2010 to 440 million [ 13 ] and is forecasted to be 1,555 million by 2050 [ 49 ].

The physical changes inherent to ageing can reduce autonomy and functional independence, which may directly or indirectly lead to falls. Falls are coded as E880–E888 in the International Classification of Disease-9 (ICD-9) and as W00–W19 in ICD-10, being commonly defined as “inadvertently coming to rest on the ground, floor or other lower level, excluding intentional change in position to rest in furniture, wall or other objects” [ 84 ]. About one third of the population over 65 suffers at least one indoor fall every year [ 33 , 47 ], and about half of the population in this age group who is institutionalised fall each year [ 33 ]. Among the elderly, falls are one of the main causes of injuries, physical incapacity and even death. Each year, around 37.3 million falls among elderly will require health care, and about 424,000 lead to death of the faller [ 19 ].

It is thus obvious that the problem of falls among the elderly population has epidemiological levels with a global incidence and dimension. Therefore, the following question was posed: What are the physical consequences of falls in the elderly population?

In order to answer this question, a quantitative review was conducted. This paper aims at identifying, categorising and analysing the typical ageing and fall factors mentioned in the literature as well as quantifying the number of times these factors were referenced. This study considered the incidence of the anatomic characteristics and physiological consequences of ageing, the pathologies that power falls, causes and risk factors for falls, physical consequences of falls and strategies to prevent, mitigate and rehabilitate.

This work is focused on providing an overview of the published literature to researchers, academics and practitioners, who deal with this issue; it does not cover the entire research area of elderly population falls.

Materials and methods

The research was limited to peer-reviewed articles, written in English and published in scientific journals or magazines between the years 1995 and 2010. The research was restricted to the following databases: PubMed , Access Medicine , Science Direct , Oxford Journals and Taylor & Francis Online . Additionally, a manual search was carried out for the other publishers in the areas already mentioned, such as McGraw-Hill and BioMed Central as well as publications edited by organisations that focus the problem of falls in the elderly people, such as the National Center for Injury Prevention and Control and the World Health Organization .

The keywords used, as title and/or abstract and/or keywords of the articles, either for searching scientific publications databases or for manual search in other online publications, were the following: “physical consequences of falls”, “senior population and falls”, “falls pathologies”, “anatomy of ageing”, “causes of falls” and “risk factors”.

After the search, the titles and abstracts were analysed in order to eliminate duplicates and publications with topics that did not meet the purpose of this review work. The remaining publications were thoroughly read and analysed, and all references to the topics addressed in the review article were identified and quantified.

Search results

A total of 87 publications were selected and analysed, from which 81 were journal publications from scientific database and 6 were articles published in book chapters or specialty reports obtained from the manual search. The publications came from 25 different countries in the world and represent all continents with the exception of Africa. The strongest geographic incidence, with about 82 % of the total publications was identified in two continents: North America and Europe. South America and Asia represent 18 % of the total publications. Publications from Turkey, Israel and Iran were considered as being from the Asian continent.

Ageing pathologies that potentiate falls

Falls are events that depend on multiple factors and can be related to the presence of pathologies. The pathologies inherent to the process of ageing, which may lead to fall in the elderly population, are numerous and diverse. Therefore, four categories were considered: neurological, musculoskeletal, cardiovascular and other pathologies (see Table  1 ). The neurologic and musculoskeletal pathologies were the most referenced in the analysed literature. The cardiovascular pathologies also had a considerable incidence of references, although small when compared with the former. Table  1 shows the references in the literature for each pathology type and the number of times they were referenced (in percentage).

In the selected literature, the neurological diseases, such as stroke (13.7 %), dementia (10.3 %), vestibular disorders/balance (10.3 %) and Parkinson (9.1 %), are the most referenced ageing pathologies as propitiating falls in the elderly population.

In terms of musculoskeletal pathologies, osteoporosis was the pathology with a higher incidence of references (16 %), followed by loss of muscle density (9.1 %) and arthritis (6.8 %). Problems in the lower extremities and joint deformities were also diseases common in the falling elderly, but with a lower incidence of references (3.4 and 2.2 %, respectively).

Cardiovascular diseases, such as orthostatic hypotension (6.8 %), arrhythmias (3.4 %) and syncope (3.4 %), are also common pathologies due to the ageing process and may also lead to falls.

In the “other pathologies” category, the following typical pathologies of ageing that can lead to falls were identified: diabetes and depression (4.5 %), pneumonia and lung infections (2.2 %) and sleep disorders (1.1 %).

The causes and risk factors of falls

Table  2 identifies multiple causes and risk factors of falls in the elderly population as well as the respective incidence in the reviewed literature. The causes and risk factors of falls are very diverse, and several of these factors can occur simultaneously. Due to that diversity, the causes and risk factors of falls were grouped in four categories, analogous to those adopted by the World Health Organization, in WHO Global Report on Falls Prevention in Older Age [ 84 ]:

Behavioural , characteristics of human actions, emotions or daily choices;

Biological , individual's characteristics pertinent to the human body;

Environmental , interactions between the individual's physical condition and the surrounding environment;

Socio-economic , related to the individual's social and economic situation.

The results of this analysis are shown in Table  2 . The behaviour causes and risk factors most referenced in the reviewed literature were overdose of medication (with 32.1 %) and the fear of falling—without having ever fallen before or after the first fall (29.8 and 22.9 %, respectively). The reduction in physical activity (16 %), carrying out activities of daily living (11.4 %) and alcohol consumption (10.3 %) are located in the intermediate incidence group. In the smallest incident group, the following were identified: slip (6.8 %), fainting (4.5 %) as well as smoking and an inappropriate use of footwear (both with 3.4 %).

Concerning the biological causes and risk factors , highest incidence was on a lack of balance during gait (33.3 %), musculoskeletal and sensory degradation (26.4 %), functional dependence in the mobility (25.2 %), cognitive impairment (24.1 %), age (19.5 %) and sex (18.3 %) with higher incidence in females. The decrease in bone density and lack of vision (with 14.9 % each), chronic diseases (13.7 %), depression (12.6 %), occurrence of dizziness and vertigo (11.4 %) and decrease of index bone mass (10.3 %), which weakens the ability to absorb and dissipate impact forces, were intermediate incidence factors. Finally, urinary incontinence, orthostatic hypotension, pain, soft tissue changes, hearing problems and body weight, with between 3.4 and 4.5 % incidence, were identified as causes and behaviour risk factors with least references in the reviewed literature.

With respect to the environmental causes and risk factors , unsafe domestic (17.2 %) and outdoors (16 %) environments were found to have the highest incidence. Falls from hospital beds, mobility aids (for example walkers) and the collision against objects were referenced only one to two times.

Last, the socio-economic causes and risk factors of falls included limited access to health and social services (2.2 %), low income and low educational level (2.2 %) and lack of social interactions (1.1 %). This category had the lowest number of references in the literature, when compared with the other categories of causes and risk factors.

If a profile is established for a senior individual with a high risk of falling based simultaneously on the causes and risk factors more referenced on the four categories, the overall risk of falling and consequent injury gravity for that individual can be expected to be very high.

Physical consequences of falls and physiological effects

Falls among the elderly are associated with a large diversity and heterogeneity of undesired physical consequences, which can be more or less severe. Four main categories were considered for the physical consequences: fractures, bruises, injuries and “other” physical consequences. A fifth category was also defined, focused on the physiological effects associated to the physical consequences of falls.

The results concerning the physical consequences and the physiological effects of falls are shown in Table  3 . It was observed that fractures (as consequences of falls) can occur in almost every region in the body. However, the hip fracture and undifferentiated bone fractures are the most referenced in the literature, with 37.9 and 27.5 % incidence, respectively.

The head bruises due to falls, with 10.3 % incidence, were the more referred physical consequence in the bruises category.

For the injuries category, the incidence of references in the literature is more homogeneous than in other categories. The most referenced injuries are soft tissues and the upper extremities, respectively with 6.8 and 5.7 % incidence. Injuries on the elbows are the ones that had the least incidence, namely 2.2 %.

For other consequences , lacerations with 8 % and dislocations with 5.7 % incidence were the most referenced in the literature. This category also included sprains, hematomas and pain, but these were identified in the literature to a smaller extent.

The physiological effects of elderly falls were also identified. The two effects with higher incidence of references were death and morbidity, with 21.8 %, and functional decline, with 20.6 %. Other still significant effects were inactivity, with 14.9 %, functional dependence and loss of autonomy, with 13.7 %, and depression, with 10.3 % incidence.

This analysis reveals a possible cause–effect relation between the different physiological effects. For example, depression can lead to higher functional dependence; in the same way, inactivity can lead to functional decline. On the other hand, the state of physical incapacity and functional dependence as a result of a fall can retract the ability to participate in everyday life activities and increase the chance of depression. These interrelations between causes will be further explored in future work.

Interventions for prevention, rehabilitation and minimization of falls

Many actions, strategies and mechanisms can—and have been—employed for the prevention, minimization and rehabilitation aspects of elderly falls. The different interventions can be categorised into three groups: the first group consists of physical interventions, the second of environmental interventions, and the third with behavioural interventions. For each of those, one can correspond them to the three stages associated with falls: the moment before the fall (interventions to prevent falls), the time during the fall (interventions to minimise the consequences of falls) and the moment after the fall (interventions related with the rehabilitation of the consequences of falls).

The different interventions, related to falls, as well as the respective percentage of references incidence are indicated in Table  4 . For each type of intervention (physical, environmental and behavioural), Table  4 also shows at which stage of the fall event they can be applied (prevention, minimization and rehabilitation). Note that these stages are not mutually exclusive.

The physical interventions are those that represented the highest incidence: most notably, adjustment of medication with 18.3 % incidence, hip protection coating systems with 17.2 % incidence and the use of strengthening nutrition programmes with 11.4 % incidence.

The environmental interventions were those that exhibited the lowest incidence and were essentially limited to changes in the home and public environments to reduce the risk of fall, with 11.4 % incidence. Note also that the other intervention “removal of obstacles in the household” is directly related to the former.

Finally, in the behavioural interventions, the highest incidence, of 21.8 %, was found for carrying out activities and exercise. The use of rehabilitation methods based on gait training and management of risk factors of multiple falls, with an incidence of 14.9 and 10.3 %, respectively, were also relevant types of behavioural interventions.

Concluding remarks

In this review article, we have quantitatively characterised relevant research efforts on this issue of great social relevant over the last decade and a half, by identifying the incidence of articles concerning the anatomic characteristics and physiological consequences of ageing, the pathologies that propitiate falls, the causes and risk factors for falls, the physical consequences of falls and the strategies to prevent, minimise or rehabilitate.

This study will be useful both for those who want to identify key research issues and those who study ageing from the perspective of social sciences. In the future, repeating this study for the period of 2011–2025 will provide a historical time frame for analysis and comparison.

In subsequent work, we aim to study the economic impact of falls, from the individual and societal perspectives.

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Acknowledgments

We acknowledge the Foundation for Science and Technology (FCT), Lisbon, through the 3º Quadro Comunitario de Apoio, the POCTI and FEDER programmes, project PEst-C/CTM/LA0025/2013, and FCT scholarship SFRH/PROTEC/67465/2010. Partial support has been provided by project PT21, no. 13848, co-financed by the European Community Fund through COMPETE Programa Operacional Factores de Competitividade. The financial sponsors played no role in the design, execution, analysis and interpretation of data or writing of the study.

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Terroso, M., Rosa, N., Torres Marques, A. et al. Physical consequences of falls in the elderly: a literature review from 1995 to 2010. Eur Rev Aging Phys Act 11 , 51–59 (2014). https://doi.org/10.1007/s11556-013-0134-8

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Mental Health Considerations in Older Adults: a literature review

Posted on 8th August 2019 by Samina Miah

During the final year of their Paramedic Science (BSc Hons) course at Oxford Brookes University, students carry out a literature review and critical appraisal of a topic relevant to their future practice. This blog presents the abstract of a literature review on ‘ Mental Health Considerations in Older Adults ‘. Other Paramedic topic blogs can be found here .

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Effectiveness of life review on depression among elderly: a systematic review and meta-analysis

Bushra rashid al-ghafri.

1 Department of Family Medicine and Public Health, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman

Abdulaziz Al-Mahrezi

Moon fai chan, introduction.

depression is considered one of the most common obstacles to daily life activities and quality of life in the elderly. Evidence is accumulating regarding the effectiveness of reminiscence and life review interventions in reducing depression and raising well-being in the elderly. The aim of this review was to determine the effects of life review interventions on depression outcomes among the elderly.

a search of the literature was performed through 11 electronic databases to identify all randomized controlled trials studies that examine life review effects on depression among the elderly. For each study, the effect size (Cohen's d) between groups (life review vs. control) differences in depression scores for post-intervention and follow-up intervention were computed.

in total, 15 studies were met the inclusion criteria and was evaluated by meta-analysis. Results showed that the life review group has a large effect on reducing depression level than the control group on post-intervention and follow-up. After conducted sensitivity analysis, a moderate effect (effect size=-0.54; 95% CI=-0.71 to -0.36; p<0.05) and small effect (effect size=-0.20; 95% CI=-0.41 to -0.01; p<0.05) were found on post-intervention and follow-up, respectively.

through this systematic review and meta-analysis, the overall results showed a moderate effect to reducing depression levels among the elderly in the life review group after carrying out post-intervention measurements, while in the follow-up the effect was small. This review indicates that life review intervention is one of the options likely to be of benefit for elderly in primary care settings, but further research can be focused on intervention and follow-up durations to obtain long-term effects.

The number of older people in every corner of the world keeps rising, creating a challenging issue of health and well-being. This growing number of the elderly has been termed as the silent revolution [ 1 ]. As one ages, his or her physical and mental strengths weaken, leading to physical, mental, and social changes that affect the elderly´s quality of life [ 2 ]. Depression is considered one of the most common mental disorders hampering daily life activities and reducing quality of life in the elderly [ 3 - 7 ]. Major depression usually affects the age group of 55 years and above, accounting for 1.8% of the general population, while minor depression occurs in 9.8% [ 8 ]. Studies on health care costs have demonstrated that older adults with depression have higher health costs than do their non-depressed counterparts, regardless of the presence of other chronic diseases [ 9 ]. Depression can accelerate or exacerbate pain, malnutrition, functional disability [ 10 ], and lowered immunity [ 11 ]. The elderly with depression are three times more likely to have high blood pressure than those of their age who are not depressed, and they are more likely to develop hip fractures, heart attacks, pneumonia, and other infections [ 11 ]. There is strong evidence that reminiscence and life review interventions are effective in reducing depression and raising well-being in the elderly [ 12 , 13 ]. Most of the time, the two terms ‘life review´ and ‘reminiscence´ are used interchangeably, but they may not be properly interpreted.

According to Butler, life review is defined as “a naturally occurring, universal mental process characterized by the progressive return to consciousness of past experiences”. It involves recollecting, evaluating and assigning meaning to positive and negative one´s personal memories [ 14 , 15 ]. Reminiscence is a part of life review and a facilitator of it. Haight and colleagues described it as “a rubric with several different functions and represent different reminiscence phenomena” [ 16 , 17 ]. Life review is the most common approach among other treatments for depression [ 18 ] in older adults based on evidence, which is specific for the elderly. It was found through meta-analyses that life review shows important and essential effects on depression and other psychological well-being [ 14 , 19 ]. The studies were heterogeneous in terms of the evaluation elements, the number of sessions, the time, and the methods of motivation to review life. Some studies included verbal stimuli alone, whereas some others used pictures, music, and albums [ 20 ]. According to recent meta-analysis studies, additional evidence for long-term effects and follow-up periods (of at least one year) is required. Previous studies only evaluated symptoms of depression but not depression itself as an outcome [ 21 ]. As a whole, this study aimed to perform a systematic review, focusing on the effects of life review on depression as an outcome in the elderly by considering the number of sessions, the time, the measuring tools of the outcome, the duration, and other related elements.

This systematic review was implemented and written using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines [ 22 ].

Inclusion and exclusion criteria: the type of studies included in this review was randomized controlled trials (RCT) and the type of intervention was any form of life review compared to no treatment or control. The participants of interest were the elderly at the age of 60 years or older with depression as the outcome. The search limits included full-text articles with available abstracts in human science, general medical, psychiatry, education, counseling, biography and autobiography, social scientists, and psychologists. This review excluded the observational studies and other types of studies (e.g. survey, reviews, and study protocol). We also excluded studies that included participants with Dementia or Alzheimer disease or undergoing other types of intervention (e.g. music therapy, yoga, or cognitive therapy). In addition, articles published from books, e-books, newspapers, and magazines were excluded too.

Search strategy: literature study was done by collecting the relevant data from the library of the Sultan Qaboos University. The key words used in the search engine were the terms as “life story”, “storytelling”, “reminiscence”, “reminisce”, or “life review”, and “depression”, “older adults”, ”elderly”, “geriatric”, ”geriatrics”, ”aging”, “senior”, “seniors”, or “older people”. Within the limits of the research were articles published in English and Arabic languages between 1981 and March 2021.

Data sources: the articles were collected from the following databases: embase medline, academic search ultimate, CINAHL Plus, CAB Abstract, ERIC, Agricola, Cochrane Library, Green file, Science Direct, Google Scholar, and Springer.

Data extraction and quality assessment: data were extracted from articles included in this review with the following information: author´s name, year of publication, country, the total number of samples, the content of intervention and control groups, numbers of females and males, age, sessions period and time (in weeks), dropout, outcome measuring tool, form of delivery (individual/group) and results (during post-intervention and follow-up periods). Post-intervention is the period of taking outcomes after applying intervention immediately, while in the follow-up the outcomes were measured after a period of time spanning several weeks after finishing the intervention. According to the Joanna Briggs Institute (JBI) critical appraisal checklist for systematic reviews [ 23 ], the obtained full-text articles were evaluated to estimate the quality of each study. The initial search and screening the title and abstract was conducted by one researcher (BRG). A full-text was conducted by two researchers (BRG and MFC) to assess the eligibility. One researcher (AM) was consulted whenever a disagreement arose between other two researchers (BRG and MFC) but there were no discrepancies. At the end, a total of 15 studies were included in the final analysis.

Statistical analysis: descriptive statistics (e.g. mean, standard deviation, frequency) were used to describe the characteristic of each reviewed study. Meta-analysis was used to integrate all reviewed studies and estimate the overall effect sizes of the life review against control [ 24 ] on depression level. Depression score is the outcome measure of each reviewed study. All reviewed studies, including the number of samples, mean, standard deviation (SD) on depression of the life review and control groups were extracted. For each study, the effect size (Cohen´s d) between groups (life review vs. control) differences in depression scores for post intervention and follow-up intervention were computed. An effect size interpreted as small (0 to 0.32), moderate (0.33 to 0.55), or large (0.56 or higher) according to previous studies [ 25 , 26 ]. I 2 and Cohran´s Q statistics were used to assess homogeneity across studies [ 27 ] for post-intervention and follow-up intervention. Random-effects model was used to calculated the pooled effect size for after intervention and follow-up because the I 2 50% and the p-value on Q statistic < 10% were shown as heterogeneity of the reviewed articles. Since, there was a significant heterogeneity across studies, sensitivity analysis was conducted to identify the presence of publication bias by using funnel plot and Egger's test. The acquired data were analyzed using the MedCalc 12 statistical software.

Study selection: one thousand three hundred and eleven abstracts were obtained in the first search, out of which 407 duplicates were removed, leaving 904 results. Furthermore 472 irrelevant publications were excluded, therefore there were only 432 sought for retrieval, while 25 remained for screening for the title and abstract by looking at the full-text articles for eligibility assessment; 8 studies were excluded because they failed to meet the inclusion criteria, and another 2 were excluded due to lack of relevant data. Thus, 15 studies were included in this review and analyzed according to the Intensive Behavioural Intervention (IBI) critical appraisal checklist for systematic reviews. The publication selection flow chart showed the specific outcomes and causes ( Figure 1 ).

publication selection flow chart

Studies quality: in all studies, participants were randomly assigned, and allocation to groups was concealed. Regarding the similarity of the treatment groups at baseline, the difference was only found in two studies. One of which [ 28 ] showed no similarity, while the other [ 29 ] remained unclear. In addition, only one study [ 29 ] showed that the participants were blind to treatment assignment. Besides this, the same study and two other studies [ 30 , 31 ] showed that the treatment assignment was hidden from the treatment providers. Regarding follow-up completion, two studies [ 28 , 29 ] were unclear on this aspect. One study [ 30 ] also remained unclear for the relevance of trial design to the topic. The quality assessment results of the included studies are shown in Table 1 .

quality of included randomized controlled trial (RCT) studies in the systematic review using JBI RCT checklist

Y:yes; N:no; U: unclear; NA: not available; JBI: Joanna Briggs Institute; Q1: was true randomization used for the assignment of participants to treatment groups?; Q2: was allocation to treatment groups concealed?; Q3: were treatment groups similar at the baseline?; Q4: were participants blind to treatment assignment?; Q5: were those delivering treatment blind to treatment assignment?; Q6: were outcomes assessors blind to treatment assignment?; Q7: were treatment groups treated identically other than the intervention of interest?; Q8: were follow-up complete and if not, were differences between groups in terms of their follow-up adequately described and analyzed?; Q9: were participants analyzed in the groups to which they were randomized?; Q10: were outcomes measured in the same way for treatment groups?; Q11: were outcomes measured reliably?; Q12: was appropriate statistical analysis used?; Q13: was the trial design appropriate, and any deviations from the standard RCT design (individual randomization, parallel groups) accounted for in the conduct and analysis of the trial?

Studies characteristics: the number of studies included in this review was 15 with a total of 963 participants, among which there were five studies conducted in the USA, three in Spain, two in Singapore as well as in the Netherlands, and for the rest, only one study was conducted in each of the following countries: Japan, German and Iran. The studies varied in the number of sessions they included, two studies [ 31 , 32 ] contained five sessions, two studies [ 29 , 30 ] contained four sessions, five studies [ 28 , 33 - 36 ] included six sessions, and four studies [ 20 , 37 - 40 ] included eight sessions. The other two studies contained 10 sessions [ 41 ] and 12 sessions [ 42 ]. The contents of stimulating intervention to review life differed, including life review story, writing, art-based life review, remembering specific positive events, computer supplements, and autobiographical retrieval practice. All of the interventions took place individually except in two studies [ 35 , 38 ], which were in a group form. Depression levels were measured using different screening instruments such as a 20 item self-report scale (CES-D; 6 studies), geriatric depression scale-15 (GDS-15; 3 studies) or scale-30 (GDS-30; 2 studies), beck depression inventory-II (BDI-II; 2 studies), a screening instrument consists of three subscales: depression, somatization and anxiety (BSI-18; 1 study) and Zung´s depression scale (SDS; 1 study). Further details on the characteristics of the studies are shown in Table 2 .

main characteristics of the randomized controlled studies included in the systematic review

N: total samples; LR: life review; LRT: life review therapy; LRA: life review activities; LSR: life story review; ARP: autobiographical retrieval practice; IR: integrative reminiscence; F/M: female/ male; Grp: Group; wk: week; LRRA: life review reminiscence activities; ACTP-LR: a culturally tailored peer-led reminiscence; NI: no intervention; DSB: develop story book; W: writing; I: intervention group; C: control group; Ind: individual; VW: video watch; AC: attention control; PI: post-intervention measure; FU: follow-up measure; M (SD): mean (Standard deviation); V: visit; NA: not Available; hr: hour; m: minutes; SDS: Zungs depression Scale; MC: mean change; CES-D: center for epidemiologic studies depression scale; BDI-II, beck depression inventory-II; GDS-15/-30, geriatric depression Scale-15/-30;*: visit group was not shown; ABLR: art-based life review; NA: Not available; **: attention control group was not shown; MW: media workshop; RSPE: remembering specific positive events; CS: computer supplements; HE: health education; Form: format

Post-intervention effects: the meta-analysis in Figure 2A displays the post-intervention effects on 15 studies [ 21 , 29 , 30 - 42 ] of the life review compared to a control condition. The pooled data included 875 samples (life review=445 vs. control=430), and its heterogeneity was high (I 2 =94.88%) and significant (Q=273.54; p<0.001). Therefore, the random effects model was used, and it showed that the life review groups had a larger effect on reducing depressive symptoms (pooled effect size=-0.8; 95% CI=-1.47 to -0.14; p<0.05) than the control group. Publication bias was noted in a few studies from the funnel plot ( Figure 2B ). Sensitivity analysis was performed and suggested that 2 studies [ 21 , 38 ] should be excluded (Egger´s test: Z=1.109, p=0.268) and its heterogeneity was changed to low (I 2 =10.978%) and not significant (Q=13.480, p=0.335) ( Figure 2C ). Therefore, a fixed effects model was used for these 13 articles [ 29 , 30 - 37 , 39 - 42 ] and a moderate effect size was found (pooled effect size=-0.54, 95% CI -0.71 to -0.36).

A) forest plot of the meta-analysis for studies of life review group versus the control group of post-intervention on depression rating scores; B) funnel plot for 15 reviewed studies of post-intervention; C) plot for 13 studies of post-intervention after excluding 3 studies (Hanaoka 2004, Korte 2012)

Follow-up effects: the meta-analysis in Figure 3A displays the follow-up effects in 9 studies [ 21 , 29 , 31 - 34 , 38 , 39 , 42 ] of the life review compared to a control condition. The pooled data included 637 samples (life review=324 vs. control=313) and its heterogeneity was high (I 2 =96.91%) and significant (Q=258.49; p<0.001). Therefore, the random effects model was used, and it showed that the follow-up effects on life review groups had a larger effect on reducing depressive symptoms (pooled effect size=-1.05; 95% CI=-2.12 to -0.01; p<0.05) than the control group. Publication bias was noted in a few studies from the funnel plot ( Figure 3B ). Sensitivity analysis was performed and suggested that 3 studies [ 32 , 34 , 38 ] should be excluded (Egger´s test: Z=0.526, p=0.599) and its heterogeneity was changed to low (I 2 =15.196%) and not significant (Q=5.896, p=0.316) ( Figure 3C ). Therefore, a fixed effects model was used for these 6 articles [ 21 , 29 , 31 , 33 , 39 , 42 ] and a small effect size was found (pooled effect size=-0.20, 95% CI -0.41 to -0.01).

A) forest plot of the meta-analysis for studies of life review group versus control group of follow-up on depression rating scores; B) funnel plot for 9 reviewed studies of follow-up; C) funnel plot for 6 studies of follow-up after excluding 3 studies (Chan 2013, Ilali 2019, Korte 2012)

The objective of this review was to determine the effectiveness of life review on depression among elderly. The results of the included studies reported a significant reduction of depression scores in the intervention group over time. Meta-analysis results showed that the life review groups had a large effect on reducing depressive symptoms than the control groups in both post-intervention and follow-up periods when the random effects model was used. Whereas, the sensitivity analysis showed that life review had a moderate effect on reducing depressive symptoms in post-intervention and a small effect in the follow-up. With regard to the duration of data collection, we found that it ranged between 2 and 12 weeks, in which 8 weeks was the most common. All studies began to record the initial measurements at baseline, and the measurement periods varied afterward, as some studies were limited to the post-intervention period and some included follow-up after one, three, six, nine months, or one year. The results also showed that the dropout rate was greater in studies that included follow-up periods of longer duration.

By comparing studies related to the title of this review, our findings in terms of a positive effect of life review in reducing depression levels are consistent with the results found in 2003 by Hseih and Wang which stated that reminiscence therapy resulted in statistical significantly decrease in depression in elderly [ 42 ], and the explanation was given by Cappeliez et al . (2006) when they found that supporting the elderly by listening to their experiences and confessions and confirming their accomplishments helps them reformulate thoughts and reduce feelings of regret and frustration, and every negative thing associated with depression [ 43 ]. In addition, regarding duration of data collection on follow-up which lasted in 8 weeks for most of the studies, this reinforces the conclusion of Haight and Haight in 2007 [ 44 ] that a minimum duration of 6-8 weeks of data collection was better for older adults to gain the benefits from life review. This has been explained by Lan et al . (2017) that the reason may be that the reviewer and the listener need enough time to gain trust and build a relationship that allows for discussing the details of life [ 45 ]. In case of long duration in follow-up periods, the causes of high dropout rate varied between fatigue, the burden of symptoms, or death. This might explain the lack of studies with long-term effects and follow-up periods in this area.

The meta-analysis focused on how effective the life review on depressive symptoms to the elderly on post-intervention and follow up compared with the control group. Initially, 15 and 9 studies were used to identify the pooled effects of life review on depression level for elderly at post-intervention and follow-up, respectively. Significant heterogeneity results were found in both periods, so sensitivity analysis was performed to identify studies with high publication bias that induces such heterogeneity. After removing those highly heterogenous studies, 13 and 6 studies showed homogeneity on post-intervention and follow-up, respectively. A moderate effect on reducing depression level was found on post-intervention which are similar to Lan et al . (2017) [ 45 ] but a large effect was found from Westerhof and Slatman (2019) [ 22 ]. In addition, Westerhof and Slatman (2019) reported a moderate effect size on the follow-up, but a small effect size was found in our study. One of the reasons may be due to the number of weeks; while Westerhof and Slatman (2019) focused on studies of 12 weeks duration only, the duration of the studies included in this review ranged from 6 weeks to 52 weeks. This finding might indicate that follow-up time is a moderating factor that affects the depressive symptoms in the elderly. Another reason for the loss of effects at follow-up may be due to the smaller number of available studies that provided follow-up data.

The strength of this review is that it reinforces previous research confirming the effectiveness of life review in improving depression levels in elderly. It also gathers studies varied in locations as they were conducted in different countries, leading to diversity in environments and cultures, which means that the elderly who suffer from depression may have different beliefs which highlights a new point to focus on for future search and makes these findings stronger. The review also had some limitations: the search for studies was limited to English and Arabic only. There may be other studies conducted in different languages which were not included. The variation in the content of the intervention methods (e.g. life story review, reminiscence, life review therapy) and tools of outcome measurement among studies leads to determining which methods or measures were the best to enhance the review of life or make it more effective. It may be better for future research to focus on one type of intervention and on a specific scale to determine the most effective. This study focuses on only depression as an outcome could be considered a limitation, as life review could impact on other psychotically aspects (e.g. meaning in life) early on that affect their quality of life. Besides, the findings cannot be generalized to other countries than those in which the included studies were conducted, particularly for the Arab countries where the culture and the health care systems are different from the Western or Asian countries. This provides another area for future research by focusing this type of research on Arab countries.

Through this systematic review and meta-analysis, we aimed to provide healthcare professionals with a comprehensive summary of the available evidence on the effects of life review interventions on depression levels among the elderly. Despite a large variation in the sample size, contents and duration of the intervention, measurement tools, and publication bias, the overall results showed a moderate effect to reducing depression levels among the elderly in the life review group after carrying out post-intervention measurements, while in the follow-up the effect was small. This review indicates that life review intervention is one of the options likely to be of benefit for elderly in primary care settings, but further research can focus on intervention and follow-up durations to obtain long-term effects.

What is known about this topic

• Depression is considered as one of the most common obstacles to daily life activities and having a good quality of life in the elderly;
• Life review interventions are effective in reducing depression in elderly on post-intervention but the effect is unclear on the follow-up.

What this study adds

• Life review intervention has a moderate effect to reducing depression levels among the elderly on post-intervention, while in the follow-up the effect was small;
• The reviewed studies varied in specific protocols used and the delivery format but all of them included life review as an intervention;
• Duration of data collection during follow-up period can affect the depressive symptoms in the elderly.

Acknowledgments

We thank the supports of the Institution library for collecting all related information.

Cite this article: Bushra Rashid Al-Ghafri et al. Effectiveness of life review on depression among elderly: a systematic review and meta-analysis. Pan African Medical Journal. 2021;40(168). 10.11604/pamj.2021.40.168.30040

Competing interests

The authors declare no competing interest.

Authors’ contributions

Study design: Moon Fai Chan; data collection and analysis: Bushra Rashid Al-Ghafri, Moon Fai Chan; manuscript preparation: Moon Fai Chan, Bushra Rashid Al-Ghafri, Abdulaziz Al-Mahrezi. All the authors have read and agreed to the final manuscript.

• Open access
• Published: 17 June 2024

Cognition of diet quality and dietary management in elderly patients with coronary and other atherosclerotic vascular disease in western China, a qualitative research study

• Jiamengying Chen 1   na1 ,
• Xiaojie Li 1   na1 ,
• Yun Wang 2 ,
• Chunling Zhang 3 ,
• Li Yang 3 ,
• Lvheng Zhao 1 ,
• Qingqing Zhu 1 ,
• Li Wang 4 &
• Yixia Zhou 1 , 2  

BMC Geriatrics volume  24 , Article number:  525 ( 2024 ) Cite this article

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Metrics details

Healthy eating is one of the most important nonpharmacologic treatments for patients with atherosclerosis(AS). However, it is unclear how elderly AS patients in western China perceive their dietary status and which type of nutritional assistance they would be willing to receive. Therefore, the primary purpose of this study was to understand the level of knowledge about current dietary habits and healthy eating habits among elderly AS patients in western China, and the secondary purpose was to identify acceptable nutritional assistance measures or pathways for those patients to help them manage disease progression.

An implementation study approach was used to recruit elderly patients with AS-related diseases in western China for semistructured interviews.

14 participants were included in the study, and the following three themes were identified from the interviews:(1) the diet with regional characteristics; (2) low nutrition-related health literacy; (3) complex attitudes towards nutritional assistance. Most participants had misconceptions about healthy eating, and the sources of their knowledge might not be trustworthy. Participants expressed a preference for personalized nutritional assistance, especially that provided by medical-nursing combined institutions.

Patients in western China need nutritional assistance for their regional dietary habits; therefore, healthy dietary patterns consistent with the regional culture are proposed to improve the prevailing lack of knowledge about healthy diets, improve the dietary structure of patients, and control the development of the disease.

Peer Review reports

Patients generally misunderstand dietary information, and their perceptions of dietary quality are different. With improvements in people’s living standards and a general lack of exercise, the incidence of atherosclerosis (AS) is increasing annually. The main incidence group is still the elderly population [ 1 ], and this disease has brought a greater economic burden to people and medical systems [ 2 ].

Poor eating habits are a definite risk factor for AS and one of the important risk factors associated with the burden of cardiovascular disease (CVD) [ 3 ]. In 2016, 2.1 million global deaths from CVD were linked to poor eating habits [ 4 ]. Many studies had shown that most people with AS have poor diet quality and poor knowledge of healthy diets [ 5 ]. Global comparative risk assessment studies have estimated that hundreds of thousands or even millions of deaths in patients with CVD can be attributed to the effects of certain diets and environments [ 6 ]. In China, many scholars had investigated the dietary behaviour of patients with AS. With the further development of the economy and the steady increase in the degree of urbanization [ 7 ], Chinese consumption of fruits, dairy products, snacks, fast food and beverages is increasing significantly, and the dietary pattern is gradually shifting to a high-fat Western diet [ 8 ]. This tendency may be closely related to the increasing incidence of AS-related diseases. China is a vast country, which leads to different eating habits among people in different regions. A study of 11,512 respondents in 47 provinces of China showed that the mortality rate of CVD in the central and western regions was greater than that in the eastern provinces of China, and poor eating habits were one of the risk factors for death. However, we found that the current research is still targeting individuals living in the eastern and northern regions of China [ 9 ]. There is a lack of surveys on people in western China, which may lead to a lack of targeted and personalized nutritional assistance for this population [ 10 ].

Nutritional assistance methods include providing relevant dietary advice [ 11 ], diet intervention measures [ 12 ], diet patterns [ 13 ], nutritional supplements [ 14 ], etc. In previous studies, health education related to diet management has been shown to effectively improve the disease awareness of patients with AS and to have a positive impact on some of its indicators, such as blood lipid levels and body mass index [ 15 ]. Before designing interventions, some investigators did not consider whether participants were willing to accept nutritional assistance, and they lacked an understanding of the participants’ daily life [ 16 ]. Moreover, researchers and clinical staff may be biased against interventions recognized by patients [ 17 ]. The incorporation of the perspective of patients can help researchers explore new interventions or discover new understandings of existing interventions to form higher-quality research. Understanding local eating habits in advance can also help researchers better identify the possible bad eating behaviours of the target group and develop more targeted interventions [ 18 ].

The main purpose of this study was to explore the views of patients with coronary and other atherosclerotic vascular diseases in western China on dietary quality and previously received dietary recommendations or nutritional assistance. The secondary purpose was to determine which nutritional assistance methods are acceptable for these patients to help them improve their health management.

Qualitative approach & research paradigm

This was a qualitative study, and we used a semistructured interview method. Mainly, we discussed how patients with coronary and other atherosclerotic vascular diseases viewed their dietary habits and intake, as well as their views on various nutritional assistance methods and approaches, and explored their feelings and expectations regarding nutritional assistance.

Researcher characteristics and reflexivity

Two researchers (Li Wang, Yixia Zhou) were responsible for the research design, and 1 researcher (Li Yang) who had a clinical nurse–patient relationship with the interviewees recruited and screened participants with the assistance of 3 researchers (Lvheng Zhao, Qingqing Zhu, Yun Wang). Two researchers (Jiamengying Chen, Xiaojie Li) conducted patient interviews under the supervision of a nutrition expert (Chunling Zhang) and entered and analysed the data. A total of 9 researchers participated in this study, all of whom had research/work backgrounds related to nutrition or CVD.

From March 2023 to June 2023, elderly people who visited 3 medical institutions in Guizhou Province, China, were selected as interviewees using purposive sampling methods. The average number of elderly people in the 3 medical institutions is approximately 80 per week. A stable medical team provides medical security and regularly carries out cardiac rehabilitation and other services.

Sampling strategy

The inclusion criteria for patients were as follows: (1) \(\ge\) 60 years old; (2) diagnosed with coronary or other atherosclerotic vascular disease [ 19 ]; (3) clear thinking, able to speak Chinese fluently, including Mandarin or dialect; and (4) signed written informed consent form to voluntarily participate in the study. The exclusion criteria were as follows: (1) cognitive impairment, (2) communication barriers.

After ethical review, posters were placed in cardiovascular clinics and nutrition clinics of medical institutions to recruit volunteers to participate in the study. Information on the poster included the purpose of the study, inclusion and exclusion criteria, and contact information for the principal investigator (Jiamengying Chen, Xiaojie Li). The posters were posted from February 2023 to May 2023, and 16 elderly patients with AS were invited to participate. Due to data saturation, a total of 14 elderly patients with AS were finally interviewed and numbered P1 to P14.

Before beginning the study, the researchers invited potential participants, explained the purpose and methods of the study to the participants who were willing to participate in the study, and interviewed the participants with their consent.

Ethical issues pertaining to human subjects

Before the start of the study, the research team provided written informed consent forms to the eligible participants. This study was approved by the the Ethics Committee of The Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine (No.: KYW2022007).

Data collection and instruments

Participants participated in research interviews from March 2023 to June 2023. The interviews were conducted in a separate lounge of the medical institutions to ensure participants’ privacy. After obtaining the participants’ consent, the researchers recorded the entire interview, and all recordings were obtained using the same electronic device. All participants were interviewed by the same researcher and supervised by the chief nurses on the research team. The participants had the right to know the educational level, professional title and other information about the researchers.

According to the purpose of the study, the members of the research group conducted a literature review in advance, discussed and formulated the interview outline, and conducted a pre-interview with 2 participants in advance. According to the interview results, the outline was modified, and the interview outline applied in this survey was finally determined. The interview outline consisted of open and closed questions. The main topics of discussion were the participants’ views on the current quality of their diet, whether they feel that their diet should be improved, and whether they were willing to accept medical assistance related to diet management. In addition, the researchers asked participants whether they had received diet-related or nutritionist guidance.

At the end of the interview, the researchers listed many types of nutritional assistance or approaches to participants and asked them to provide preferences for each type of nutritional assistance or approach. Before the interview, the researchers used a warm-up question to create a friendly atmosphere between the interviewer and the interviewee: “If you do not mind, could you tell me something about your AS-related disease?”

Clinical measures

The researchers collected information such as the participants’ age, sex, and types of disease. This information was collected to provide a sufficient sample description and determine whether there was heterogeneity.

Units of study

In this study, the saturation of data collection was used as the end point of the interview process; that is, if the data analysis was repeated with the previous data, and no new coding appeared, then the interview process was considered to be completed. After data saturation, 2 participants were interviewed to ensure that no new coding appeared [ 20 ]. The interview time ranged from 11 minutes and 08 seconds to 27 minutes and 35 seconds, with an average time of 17 minutes and 42 seconds.

Data processing

During the interview, the researcher recorded the patient’s intonation, speech rate, expression, gesture and so on. To reduce the researchers’ memory bias, the recordings were converted into text within 24 hours after the end of the interview and supplemented and modified in combination with the notes of on-site observation [ 21 ] .

Data analysis

This study was conducted by 2 researchers (Jiamengying Chen, Xiaojie Li) using the Colaizzi seven-step method of phenomenological research to guide the data analysis. The 2 researchers independently and repeatedly listened to the audio recordings of the interviews, verified the content, and ultimately analysed the data separately.

During the study, the researcher verified unclear statements in the recordings by contacting the respondent via WeChat or telephone. In addition, the transcribed notes and the themes generated from the analysis were confirmed with the interviewees to ensure that their views were authentically recorded. After the information was completed for thematic extraction and coding, the research team held 1 team meeting to review it. All the researchers commented on and ultimately agreed on the themes and coding of the interviews.

Participant characteristics

Fourteen elderly patients with atherosclerotic vascular disease, with an average age of 75 years, were included in the study. Five participants were male, and 9 participants were female. The disease categories included coronary atherosclerotic heart disease, cerebral infarction, and carotid atherosclerotic plaque. Participant information is shown in Table 1 .

The results of this study show the acceptability of the current dietary status, the understanding of previous nutritional assistance, and the methods of future nutritional assistance in elderly patients with AS-related diseases in western China. The following 3 themes emerged from this study: (1) the diet with regional characteristics; (2) low nutrition-related health literacy; (3) complex attitudes towards nutritional assistance.

The diet with regional characteristics

In terms of staple food preferences, most of the elderly people included in this study claimed that they consumed rice vermicelli for breakfast and lunch because it is “easily digestible” (P3, female, 71 years old). They liked to add animal fats when eating rice vermicelli or noodles (especially ChangWang noodles from Guizhou, China), even if they knew that animal fats can be harmful to the body. These animal fats included solid animal fats and fried animal fats (known as CuiShao) to increase the flavour of the food. Another common breakfast choice among these participants was steamed glutinous rice with chili oil, soy sauce and a variety of side dishes, including “CuiShao”, bacon or sausage, fried peanuts and so on. The family members met the participants’ requests and provided them with this type of food.

“I eat either rice vermicelli or ChangWang noodles every morning. Sometimes (I) do not want to go downstairs, and I let my son or daughter bring it back to me. I think ChangWang noodles need a lot of “CuiShao” to be delicious.”

(P14; Male, 73 years old)

Some participants also said that they were not keen on eating refined rice products or noodles but preferred coarse grains, mainly including “corns, sweet potatoes, and potatoes, because this state produces potatoes” (P8; Female, 66 year old). The discussed cooking methods for the potatoes mainly including frying, fire baking and stir-frying.

“I liked to eat potatoes when I was young, and I also like to eat them now. When I was younger, I would bake my potatoes, but now I prefer fried potatoes.”

(P12; Male, 81 year old)

Some male participants favoured alcohol. They mainly consumed Chinese Baijiu, but all of them reduced their alcohol consumption after learning that they suffered from AS-related diseases. Female participants widely mentioned that they would like to drink Chinese rice wine (Mijiu) (especially homemade) rather than Chinese Baijiu and considered Chinese rice wine (Mijiu) consumption a habit that “everyone in Guizhou should have” (P9; Female, 83 year old).

“I used to drink at least 100 ml of Chinese baijiu; after learning that I was sick, I quit drinking.”

(P13; Male, 64 year old)

Most participants believed that their dietary intake was healthy, while some participants said that after the diagnosis of AS-related diseases, they consciously chose to eat more vegetarian foods, such as ‘Suguadou’, a specialty of Guizhou Province, China, and avoid consuming animal fats.

“After I got sick, I gained some knowledge from the newspaper and TV. It was said that eating a vegetarian diet is good for my health. [Now] I eat a vegetarian diet and do not eat chicken, duck or fish.”

(P2; Female, 61 year old)

Other participants said that they liked and frequently ate “red sour soup”, a Chinese Guizhou specialty, 2 to 3 times a week, or even more frequently. They cooked “red sour soup” in dishes by adding water or soup stock and boiled freshwater fish, lean meat and vegetables. They expressed their preference for ethnic-specific eating habits, and even if they chose to eat out, they would more frequently choose restaurants that sell “red sour soup” because “fish is easy to digest for elderly individuals, so we eat fish in sour soup at restaurants, and we like that too” (P13; Male, 64 year old). Some participants expressed their recognition of the simple cooking method of “red sour soup”. Many participants mentioned their decreasing food intake after entering old age, and they indicated that “I cannot eat much, and they say that the amount of one meal I eat is equal to the amount of one meal that a cat eats” (P4; Female, 77 year old), emphasizing “You need to eat something sour to get an appetite” (P3; Female, 71 year old).

“People in Guizhou should eat red sour soup; I have to eat it several times a week.”

(P11; Male, 82 year old)

For the intake of fruit, many participants thought that fruit consumption was a treat because their family or caregivers did not allow them to eat too much other food outside of dinner, and being provided with fruit could make them feel happy. “They did not allow me to eat too much fruit, and every time I ate fruit, they were worried that my blood sugar would rise” (P1; Female, 90 year old). The participants usually actively discussed their preferences for fruits, including buying their favourite fruits at the market or asking their caregivers to provide some fruits. Some participants mentioned that they liked to drink rosa roxburghii Tratt (RRT) juice or directly ate sliced fresh RRT for “vitamin C supplementation” (P9; Female, 83 year old).

“This plant [RRT] was widely cultivated in my hometown, and when it was ripe, we picked the fruit and ate it. It became a habit!”

(P7; Male, 80 year old)

Low nutrition-related health literacy

Most of the participants did not receive professional nutritionist consulting services and did not know that the hospital had nutrition-related departments. Some participants mentioned that when visiting a hospital, doctors or nurses mentioned diet-related knowledge, such as avoiding a greasy diet and not eating animal fats, but rarely explained the reasons.

“Nutrition department? The hospital has this department?” I do not know what to eat, so the doctor told me, ‘eat less oil and less salt.’ However, he did not tell me why”.

(P3; Female, 71 year old)

The majority of participants stated that they could use the internet to gain much knowledge about healthy eating patterns. In addition to professional notification, participants also obtained diet-related knowledge through newspapers, television, online short video publicity, family notification, etc. “(I) watched many of these kinds of videos on my telephone” (P5; Female, 62 year old). However, they had no way to tell whether the information was correct These information sources contained contradictory content, which made participants unable to distinguish the correctness of the information. Other participants said that they could not learn diet-related knowledge through commonly used health education methods, such as public accounts, videos, and brochures, in tertiary hospitals due to the degradation of vision and hearing caused by age.

“I’m old, my eyesight is poor, and I cannot see with my glasses! I also want to read the brochure [on nutrition], but I cannot see it clearly”.

Most participants could list the relevant nutritional knowledge they knew, and they also performed a small number of healthy eating behaviours, such as the most basic behaviours: quitting smoking and drinking. They believed that the implementation of a healthy diet contributes to recovery from the diseases.

“I stopped smoking or drinking after I got sick! I know that these [cigarettes, alcohol] are not good for the body” .

Some participants blindly implemented diet-related knowledge after acquiring it. These participants believed that consuming dietary supplements can ensure good health, so visiting medical institutions was unnecessary. They thought that the greater the intake of dietary supplements, the better the body they would have, even if their health might be harmed by excessive intake.

“I hardly go to the hospital because I eat a lot of health supplements; my body is fine, and I am fine”.

(P8; Female, 66 year old).

Although in medical institutions, participants received health education on diet-related knowledge, not all patients were able to effectively implement the information. Some patients were not willing to implement the recommended healthy eating patterns, and they did not want to change their preferences. The participants had different understandings of healthy eating patterns. Some participants were aware of systematic dietary patterns that they described as “good” but “difficult to implement” (P2; Female, 61 year old). Others described these eating patterns as “unpalatable”. A common view is that the ingredients of these dietary patterns are difficult or inaccessible to them.

“No, no, [they want me to] eat so many vegetables, like I am a rabbit! I have maintained my eating habits for so many years and cannot change them. These diets are weird; I do not eat avocados, I do not eat oats. If I can live to be a hundred years old if I eat these things, then I would rather die at age eighty”.

(P1; Female, 90 year old)

In addition, many participants said that doctors and nurses could not monitor whether they consumed a healthy diet after leaving hospitals. It is difficult to follow a healthy diet after discharge, especially when most patients and their families do not have a medical background.

“After I was discharged from the hospital, they [the doctors and nurses] did not know what I was eating at home. Doctors and nurses are very busy with work; how can there be time to help us with our eating?”

Complex attitudes towards nutritional assistance

Participants generally expressed fear of diseases. They said, “This disease will stay with me for the rest of my life, and I cannot cure it” (P12; Male, 81 year old). These participants elaborated on their desire to become healthier through nutritional assistance, and they also tended to be more willing to receive dietary-related guidance and assistance and viewed the role of nutritional assistance in delaying the development of AS positively. Personalized nutritional assistance received a positive response from the participants, and they were willing to try nutritional assistance that would help them.

“I dare not to do anything when I suffer from this disease because I fear that something will happen to my blood vessels..... Of course, it is good to be able to eat healthier; people live to eat three meals a day. If the meal tastes good and the body can be healthy, then I will wake up laughing in my dreams” .

The vast majority of participants expressed their willingness to use customized recipes, diet lists, etc., but the implementation process required the understanding and support of their families. Two male participants said that “My wife is the head of the family”, and whether to use custom recipes and diet lists required the cooperation and consent of his wife. Other patients said that because they are old, whether they could cook according to the recipe required the cooperation of their sons and daughters or caregivers (paid by the elderly individuals themselves or their families).

“We are all old and need help with daily activities such as eating and dressing. Some things require children’s help to achieve”.

(P6; Female, 81 year old)

Some participants were not very skilled in the operation of electronic devices such as telephone, computers, or televisions. They also suffered from diseases that caused them to be unable to use communication devices such as telephone. Therefore, they could not receive online health education. They only accepted one-to-one or one-to-many nutritional assistance methods that were held offline. However, some participants mentioned that they would selectively adopt the nutritional recommendations made in the meetings for the public because “not all of them suit me” (P1, female, 90 years old). Other participants suggested that they prefer to use remote online methods for meetings because they “do not have the time or energy to attend the meeting, and it is not safe if the meeting place is far away” (P7; Male, 80 year old); they were worried about traffic safety between hospitals and therefore could not attend the meetings.

“I am old, and I have no idea how to use telephone or computers for online meetings. So, I prefer offline meetings where we do whatever the doctors and nurses say” .

(P14; Male, 73 year old).

Some participants were more likely to take dietary supplements such as vitamins rather than considering other forms of nutritional assistance first. Other participants had their own views on dietary supplements; they might try to consume fresh or “medicinal” (P1; Female, 90 year old) ingredients instead of the dietary supplements prescribed by their doctors. Due to the severity of AS-related diseases, these participants were willing to receive various forms of nutritional assistance. Other participants expressed that they had too much concern and distrust regarding the use of dietary supplements. Some participants were worried about the interaction between dietary supplements and the drug treatment they were currently receiving, while other participants thought that were already using too many oral drugs, and whether dietary supplements were useful was uncertain.

“There are a lot of bad people [selling dietary supplements] now, and it is hard to identify who is good and who is bad”.

Some participants showed the opposite attitude towards nutritional assistance; they believed that they were old enough to receive intervention for their diet. Regarding the malignant cardiovascular events, cerebrovascular events, and amputations that could result from AS-related diseases, these participants stated that they “did not know and did not understand how it could be so serious” (P9; Female, 83 year old).

“I’m so old, I should eat what I want to eat” .

Most of the participants expressed their willingness to try nutritional assistance measures, which were considered beneficial for delaying the development of AS, including medical-nursing combined institutions that could provide them with a diet, but those facilities put forwards higher requirements on the price and quality of the meals. If they did not meet the requirements, they would not choose this nutritional assistance measure.

“The community should do something practical for us old people. We will eat what is good, and we do not eat what is bad”.

Some participants said they were concerned about the price of the diet provided by the medical-nursing combined institutions and were worried about their economic situation. When their income was not enough to pay for the diet provided by the medical and nursing institutions, they would not choose this method. Less income had taken away their freedom of consumption.

“We are all rural people, we have no income, and the cost of eating out is equal to the cost of a few days of our daily life..... If the food is very expensive, we will definitely be unwilling to eat it” .

The results of this study showed the acceptability of the current dietary status, the understanding of previous nutritional assistance, and the methods of future nutritional assistance in elderly patients with AS-related diseases in western China. The theme generated in this study shows that the factors affecting dietary status are multifaceted and complex, and the participants’ dietary preferences had obvious regional characteristics.

The first theme generated by this qualitative research is that the diet with regional characteristics. In this topic, we explored the relationship between participants and their food choices. We found that the participants’ diets had strong regional characteristics, reflecting the regional characteristics of the provinces in western China. The diagnosis of AS-related diseases resulted in some patients changing their eating habits, following the health education of doctors or nurses and choosing to limit alcohol consumption and eat more vegetables. For other participants, there were some difficulties in adhering to healthy eating habits; for example, the tastes and dietary preferences formed during perennial life are difficult to change. The second theme was centred on the implementation of nutritional assistance by participants. We measured participants’ understanding and implantation of knowledge about a healthy diet, which reflected their general misunderstanding of healthy diet knowledge. The third theme was that attitudes towards nutritional assistance were complex; we summarized the participants’ attitudes towards a variety of nutritional assistance approaches. Research has shown that most participants were welcoming and receptive to nutritional assistance, but other patients expressed a resistant attitude. Some participants highlighted their concerns about the price of food.

The participants discussed their current dietary intake with the researchers. In this component of the study, the participants’ dietary preferences showed obvious regionality. This study showed that the mainstream staple food choices for elderly patients with AS-related diseases in western China include rice (including refined rice and its products), glutinous rice, and some coarse grains, such as potatoes and corn. Such staple food choices were suitable for local geographical conditions but might adversely affect the health of participants. Rice products, such as rice vermicelli, were one of the main food choices that participants were interested in. They often mentioned mutton rice vermicelli, beef rice vermicelli, chili chicken rice vermicelli and so on. Most commonly, rice vermicelli and noodles were cooked in boiling water and then put into seasoned broth. Studies have shown that cooked rice flour is a moderate-GI food [ 22 ], and a higher GI index has been shown to be significantly associated with an increased risk of CVD [ 23 ]. Postprandial hyperglycaemia can lead to elevated triglycerides and increased oxidative stress, which have a negative impact on the vascular endothelium [ 24 ].

The participants often mentioned “Cuishao”, bacon, sausage, and fried peanuts. Cuishao is a unique snack and was popular among people living in Guizhou Province, China. Pork (i.e., pork belly meat with more adipose tissue mixed with lean meat) was used as the raw material, and seasonings were added to marinate and then fry the meat. The fried “Cuishao” contained a large amount of oil. Excessive intake of oil can cause a variety of adverse effects on health and may lead to a greater risk of disease, including hypertension, AS and cancer [ 25 ]. During the frying process, a series of chemical reactions, such as the oil oxidation reaction, Maillard reaction and oxidative degradation of proteins, occur in the matrix of fried meat products. These chemical reactions lead to the production of harmful substances, such as trans fatty acids (TFAs), in fried meat products [ 26 ]. Studies have shown that excessive intake of TFAs promotes vascular inflammation and oxidative stress and accelerates the development of AS [ 27 ]. Numerous academic organizations have recommended that the intake of saturated fatty acids and TFAs should be limited to regulate blood lipid levels in high-risk populations [ 28 ]. Importantly, even though the potatoes that people in western China like to eat are a good source of carbohydrates [ 29 ], the frying cooking method leads to an increase in the risk of noninfectious diseases such as CVD and diabetes by affecting inflammatory factors and vascular endothelial function [ 30 ]. This showed that when designing a diet plan for patients with AS-related diseases in western China, the patients should be asked to limit their intake of fried, high-fat foods, even if they like to eat these foods.

Most participants took the initiative to adjust their diet after being diagnosed with the disease. Some participants indicated that they had actively chosen a vegetarian diet or consciously tended to eat vegetables and fruits. People in western China often use boiled water to cook vegetables when they choose to eat vegetables and form a local characteristic dish, “Suguadou”. Commonly consumed vegetable types included kidney beans, immature pumpkin. Studies have shown that the choice of cooking method is related to cardiovascular risk factors. In addition to raw food, boiling is also a healthier cooking method, which is related to healthier cardiovascular conditions [ 31 ]. Boiled cooking methods could also better retain antioxidant compounds in vegetables. We found that people in western China like to eat a seasonal fruit called RRT in summer. This fruit is a medicinal plant and traditional food in western China. In recent years, studies have shown that RRT is rich in vitamin C [ 32 ]. The presence of other substances (organic acids, flavonoids, polyphenols, etc.) can improve dyslipidaemia through the intestinal flora [ 33 ]. Therefore, eating RRT or drinking freshly squeezed fruit juice might improve AS-related diseases.

In addition, people in western China were also keen to eat “red sour soup”. “Red sour soup” is a common fermented seasoning in Guizhou Province, China. It is mainly fermented with “Maolaguo”, red peppers, etc., followed by the addition of Litsea cubeba fruit essential oil [ 34 ]. People often use “red sour soup” to cook vegetables, lean meat slices, fish slices and so on. Studies have shown that “red sour soup” can alleviate nonalcoholic fatty liver disease induced by a high-fat diet in rats and reduce body mass index, total cholesterol, triglyceride, and insulin resistance [ 35 ]. According to a study by Yang et al. [ 36 ], red sour soup can prevent and treat hyperlipidaemia in obese rats by regulating the AMPK signalling pathway, which might be related to the antioxidant and anti-atherosclerotic effects of lycopene and capsaicin, which are abundant among the red sour soup raw materials [ 37 ].

Studies have shown that the fermentation process of red sour soup will produce beneficial bacteria such as Lactobacilli, Acetobacter , and Leuconostoc and acid substances such as lactic acid, acetic acid and citric acid [ 38 ]. These acids regulate inflammation and promote immunity, neuroprotection, and anti-ageing activity [ 39 ]. However, the impact of food as a whole on the health of organisms rather than the impact of a single component of food [ 40 ] should be noted. Therefore, it is necessary to comprehensively consider the impact of red sour soup on human health; that is, the beneficial effects of red sour soup on human health are due to its rich bioactive substances and beneficial components produced during fermentation.

Notably, some male participants mentioned frequent consumption of alcohol. Studies have shown that higher alcohol intake increases the risk of CVD mortality in Chinese men and that alcohol intake does not have a protective effect on CVD [ 41 ]. Although participants might reduce or stop consuming alcohol after the diagnosis of AS-related diseases, past studies have shown that patients who continue to drink alcohol have a similar risk of death to those who have quit [ 42 ]. This suggested that the harm caused to the human body by alcohol consumption is permanent, even if the patient has chosen to quit drinking alcohol.

This study revealed that participants generally lack healthy eating knowledge. Research has shown that among participants, there is a widespread bias towards certain types of food and a misconception regarding nutritional assistance. A survey of elderly individuals [ 43 ] revealed similar findings; for example, some participants believed that “thin” is healthy and “fat” is unhealthy, and they believed that fat, sugar, etc., are “bad” foods and prefer vegetarian food [ 44 ]. However, studies have shown that proper fat intake is beneficial to human health, and people should consume a certain amount of high-quality fat and reduce saturated fat intake [ 45 ]. The intake of omega-3 fatty acids had some benefits for participants with cardiovascular and cerebrovascular diseases [ 46 ]. Many studies have shown that a plant-based diet can promote vascular endothelial protection and reduce the generation of harmful factors in endothelial cells, which is beneficial for treating AS-related diseases [ 47 ]. A meta-analysis of 55 studies showed that compared to other eating patterns, plant-based diets and whole-grain foods are associated with better prevention of coronary heart disease and multiple metabolic diseases [ 48 ]. However, it is worth noting that even though plant-based diets have been shown to be beneficial to human health, all dietary patterns are associated with potential nutritional risks [ 49 ]. Studies have shown that long-term intake of a vegan diet may lead to a lack of micronutrients, resulting in potential nutritional risks [ 50 ]. Therefore, for elderly patients with AS-related diseases, dietary guidance should include prompting patients to choose a balanced diet, consuming abundant plant-based foods, and correcting their misunderstanding regarding their current dietary patterns.

In contrast, there were also some participants who had received relevant health education, but the information provided by the internet may conflict with it, making it difficult for them to consume a healthy diet. Numerous studies have shown that the quality of health-related information that patients can learn on the internet is mixed [ 51 ]. Many sources of information were nonprofessionals who had not received medical professional training, which leads to mixed and inaccurate or biased information that may mislead patients and even have a negative impact on their health [ 52 ]. However, even if there was erroneous or unconfirmed information, viewing internet videos was still a popular method of health education for patients. Health education, in which professional people use networks, can significantly improve patients’ compliance behaviour and reduce costs [ 53 ]. However, in this survey, some participants were unable to obtain health knowledge by reading or watching videos because of old age, illness or disability. At the same time, some participants suggested that after leaving the medical environment, doctors or nurses could not guide and supervise their diet, which led them to collect relevant health knowledge in other ways, and their compliance behaviour gradually decreased over time. Doctors or nurses should carry out continuous and personalized health education for patients. Notably, only providing advice on improving diet and activity behaviours is not enough to change and maintain these behaviours in the long run. Effective health education that supports behavioural changes requires effective incentives and promotion, including environmental support [ 54 ], and provides patients with intervention methods suitable for their culture, age and other characteristics [ 55 ].

The majority of participants accepted nutritional assistance. Our survey showed that elderly participants with AS-related diseases need personalized nutritional assistance to improve their physical condition. In addition to the need for nutritional assistance, they also need corresponding dietary support from the government or institutions because the diseases limits their physical movement [ 56 ]. At the same time, because of the decline in functional living ability, many participants showed dependence on their families. This finding was consistent with most studies [ 57 ]. With the widespread promotion of medical-nursing combinations in China, meals are increasingly being prepared by medical-nursing combined institutions rather than by the patients themselves, community health service institutions, etc., to improve diet quality. Based on the patient interviews, we found that the nutritional assistance provided by medical-nursing combined institutions may be more suitable for and accepted by elderly patients with AS-related diseases. Medical-nursing combined institutions could help elderly people with full and partial disability to solve the problems of meals, medical treatment and self-care at a lower cost. In some European and American countries, there have been similar nutritional assistance models for elderly people, but most of them involve modelled nutrition management, such as communities providing three meals a day to elderly people in the form of meal boxes. However, this intervention model cannot be used for personalized service [ 58 ].

In contrast, some participants thought that they did not need to receive nutritional assistance. They held the mentality of ‘being so old’ and had a resistant and unacceptable attitude towards nutritional assistance. This might be because they think they were old enough to no longer have to put much effort into fighting the death caused by the diseases. This study revealed that elderly people with increasing age are becoming increasingly more deeply aware of the limitations of their lives. They could accept death as an inevitable event and reduce their avoidance of death [ 59 ]. However, it should be noted that the participants’ lack of healthy diet knowledge may have led them to mistakenly believe that diet cannot significantly improve the clinical manifestations of AS-related diseases, so they still maintain unhealthy eating habits and refuse to perform healthy lifestyles. Moreover, these participants might underestimate the consequences of poor lifestyles, resulting in serious cardiovascular events, including vascular obstruction and vascular rupture. These conditions might lead to paralysis, dysphagia and other symptoms, which would result in reduced or even loss of self-care ability and a significant reduction in quality of life [ 60 ].

This study has several limitations. The research team tried to recruit participants with heterogeneous characteristics, including age, sex, family status, and education level. However, due to the purposive sampling method, the results of this study may not be extended to the wider Chinese or international population of elderly patients with coronary and other atherosclerotic vascular diseases. This study excluded individuals who did not speak Chinese. Therefore, we cannot determine whether the samples of this study included multicultural or multiethnic groups.

This study showed that elderly patients with coronary and other atherosclerotic vascular diseases who are living in western China have regional dietary preferences, which may have a certain impact on their disease development. They have different views due to differences in sex, disease status, personal habits, and modes of receiving dietary knowledge. These views are mainly regarding their own dietary status, cooking behaviours, and dietary management models. Regional and individual differences may influence the effects of diet management. In the future, for research regarding the dietary management of elderly patients with coronary and other atherosclerotic vascular diseases in western China, researchers should conduct personalized and sex-specific dietary management interventions according to their regional dietary preferences and consider whether individual patients are able to receive relevant nutritional assistance. Medical and nursing combination institutions can provide them with modelled nutrition management, such as providing three meals in the form of lunch boxes or open canteens. They can also use a variety of methods, such as face-to-face conversations and meetings, to provide them with dietary advice and flexibly use the internet to achieve online intervention. Changes in dietary behaviour may have a positive impact on the overall dietary quality of this population and may improve the patient’s disease status and prognosis.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due ethical reasons but are available from the corresponding author on reasonable request.

Abbreviations

• Atherosclerosis

Cardiovascular Disease

rosa roxburghii Tratt

Tras Fatty Acid

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Acknowledgements

We would like to thank all the participants in this study for their willingness to participate in this study and to express their views honestly.

This research was funded by the following projects: nsfc-funded project-The mechanism of MCPIP1 regulating Myocardin in vascular smooth muscle cells on atherosclerosis (No.82160099); Science and Technology Plan Project of Guizhou Province-Construction and Application of Internet of Things + Traditional Chinese Medicine Characteristic Intelligent Health Care System (No.Qiankehe support [2022] generally 263); Guizhou Provincial Health Commission Project (No.WJW-llc-H2021(11-01)).

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Nursing School, Guizhou University of Traditional Chinese Medicine, Guiyang City, Guizhou Province, China

Jiamengying Chen, Xiaojie Li, Lvheng Zhao, Qingqing Zhu & Yixia Zhou

Nursing School, Guizhou Medical University, Guiyang City, Guizhou Province, China

Yun Wang & Yixia Zhou

The Second Affiliated Hospital, Guizhou University of Traditional Chinese Medicine, Guiyang City, Guizhou Province, China

Chunling Zhang & Li Yang

School of Nursing, Suzhou Medical College of Soochow University, Suzhou City, Jiangsu Province, China

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Data curation, J.C., X.L., Y.W. and L.Z.; Investigation, J.C., X.L. and Q.Z.; Methodology, Y.Z. and L.W.; Interviewees recruited, C.Z., L.Y., L.Z, Q.Z. and Y.W.; Writing original manuscript, J.C.; Revised the manuscript, X.L. and L.W.

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Chen, J., Li, X., Wang, Y. et al. Cognition of diet quality and dietary management in elderly patients with coronary and other atherosclerotic vascular disease in western China, a qualitative research study. BMC Geriatr 24 , 525 (2024). https://doi.org/10.1186/s12877-024-05058-2

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Evidence-based green human resource management: a systematic literature review.

1. Introduction

1.1. state of the art of ghrm, 1.2. previous reviews of ghrm, 1.3. aims of the research, 2.1. identification: information sources and search strategies, 2.1.1. information sources, 2.1.2. search strategies, 2.2. screening: selection process and criteria, 2.3. included: data processing and analyzing, 3. results and discussion, 3.1. general overview of ghrm literature, 3.1.1. publications by years, 3.1.2. publications by sources, 3.1.3. publications by contexts, 3.1.4. publications by methodologies, 3.2. ghrm research foci and trends, 3.2.1. bibliographic coupling analysis, 3.2.2. keyword evolution analysis, 3.3. ghrm conceptualizations and research framework, 3.3.1. dimensions and measurements of ghrm, 3.3.2. theoretical bases of ghrm, 3.3.3. framework of ghrm, 3.4. recommendation for practitioners and researchers, 3.4.1. context and trend of ghrm, 3.4.2. access and approach to ghrm, 3.4.3. mechanism and innovation in ghrm, 4. conclusions, 4.1. summary of the research, 4.2. contribution of the research, 4.3. limitations and proposed solutions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Xie, H.; Lau, T.C. Evidence-Based Green Human Resource Management: A Systematic Literature Review. Sustainability 2023 , 15 , 10941. https://doi.org/10.3390/su151410941

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• Case report
• Open access
• Published: 18 June 2024

Gossypiboma larynx: a rare cause of post-tracheostomy stridor—case report and review of literature

• Gagan S. Prakash 1 ,
• Vikyath Satish   ORCID: orcid.org/0000-0003-4954-2620 2 ,
• Bharath Raju 3 ,
• Neema Jayachamarajapura Onkaramurthy 4 &
• Sathya Prakash 5  

Journal of Medical Case Reports volume  18 , Article number:  293 ( 2024 ) Cite this article

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Gossypiboma, a retained surgical sponge with a foreign body reaction, is an unusual but serious complication seen in open abdominal surgeries. It is exceptionally rare following head and neck surgeries. Here, we present a case of Gossypiboma of the upper airway following tracheostomy.

Case presentation

A 32-year-old male presented with stridor and difficulty breathing one-month post-tracheostomy after a severe head injury following a road traffic accident. A neck radiograph was unremarkable, and a computed tomography (CT) scan of the neck showed a well-defined homogenous curvilinear membrane extending from the hypopharynx to the upper trachea. Bronchoscopic evaluation of the larynx and upper trachea revealed a retained surgical sponge, which was retrieved. The patient’s breathing improved drastically post intervention.

Gossypiboma may go undetected in radiographs and may also present atypically as a homogenous membrane on a CT scan of the neck. Though rare, retained surgical items can have profound medicolegal and professional consequences on physicians. Hence, a strong clinical suspicion and vigilance for gossypiboma is necessary for patients presenting with respiratory distress post-tracheostomy.

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Referred to euphemistically as Gossypiboma, the term denotes a mass lesion due to a retained surgical sponge surrounded by foreign-body reaction [ 1 ]. Retained sponges in adults occur most commonly in the abdomen (56%), pelvis (18%), and thorax (11%), but their incidence in head and neck surgeries/procedures is exceedingly rare [ 2 ], and clinicians face difficulty in early diagnosis. Failure in early diagnosis can lead to increased morbidity and mortality, given its potential to cause stridor and severe hypoxemia. We report a rare case of a retained surgical sponge in the larynx of a patient post-tracheostomy. To our knowledge, this is the first reported case of Gossypiboma in the upper airway.

A 32-year-old male with no medical history who had undergone tracheostomy for a traumatic head injury one month ago returned to the hospital with complaints of exertional dyspnea and difficulty in breathing following tracheostomy decannulation. Physical examination revealed stridor, and differential causes like post-intubation/tracheostomy tracheal stenosis, pseudo-membrane, granulation tissue, and synechiae were suspected. The patient also complained of a foreign body sensation in the throat and an inability to expectorate secretions. He was clinically stable but had an elevated leukocyte count (13,400 cells/mm 3 ) and was treated conservatively with steroids, antibiotics, and albuterol nebulization.

Since the chest radiograph was unremarkable, a CT scan of the neck was performed to delineate the pathology. It unveiled a well-defined homogenous curvilinear soft tissue density in the hypopharynx, larynx, and upper trachea (Fig.  1 ). Meanwhile, the patient developed an irritant cough and severe dyspnea at rest and underwent fiberoptic bronchoscopy for further management.

Homogenous curvilinear soft tissue density in the hypopharynx, larynx, and upper trachea causing mild to moderate luminal narrowing seen on CT scan of the neck

During fiberoptic bronchoscopy, a greyish strand of glistening thick inspissated mass projecting across the vocal cords in the anterior commissure was observed. The scope was passed distally beyond the cords, and the band-like structure adhered to the anterior tracheal wall at the tracheostomy site. The cords appeared normal, with no granulation tissue or narrowing at the tracheostomy site. The tracheobronchial tree was inspected, and a thorough tracheobronchial toileting was performed. Upon withdrawal of the scope, the initial band-like structure in the larynx was not visualized anymore. Suspecting distal dislodgement, the entire tracheobronchial tree was re-visualized, revealing no band-like structure. Assuming it was a mucus strand that the patient coughed up and ingested, the bronchoscope was withdrawn. The patient complained of foreign body sensation in the throat during the visualization of the pharynx, where a thick greyish-black slimy mass was retrieved (Fig.  2 ). After thorough cleaning and examination, it was revealed to be a ribbon gauze piece covered with mucus. Following the procedure and removal of the gossypiboma, the patient improved clinically and was discharged the following day.

Gossypiboma retrieved from the larynx by bronchoscopy

Gossypiboma is a well-accepted “never event” of the National Quality Forum, USA, and is also part of patient safety guidelines by the Health Department of the UK [ 3 ]. The incidence of Gossypiboma varies by surgical site and is exceedingly rare in the head and neck region. In 2005, the Joint Commission designated retained surgical items as a sentinel event requiring immediate root cause analysis investigation and response.

To our knowledge, this is the first reported case of a gossypiboma in the larynx. Most cases go unreported due to fear of litigation and are perceived to taint a professional career. The principle of “res ipsa loquitor” (let the act speak for itself) applies to such incidents and warrants a root cause analysis.

The most probable cause for the retained sponge was the surgical gauze used to guard the tracheostomy site. Typically, a gauze is tied around the tracheostomy tube for a good seal and to prevent air leaks. Here, the patient was shifted between multiple departments, which probably lead to the missing of the fact that the gauze was packed at the tracheostomy site in the first place. It is possible that the gauze got buried under the skin post-decannulation and slowly dislodged into the trachea over time. Despite the patient’s effort to cough it up, the gauze was lodged in the larynx as one end was embedded at the tracheotomy site. The gauze was dislodged and retrieved at the end of the bronchoscopy procedure. Gossypiboma larynx presents itself earlier than at other sites and is associated with an imminent risk of airway compromise, hence warranting early intervention.

Radiographs are the most commonly used modality to detect gossypibomas. In an unremarkable radiograph, imaging modalities like CT, Magnetic resonance imaging (MRI), and Positron emission tomography (PET) aid in the diagnosis.

Established methods to prevent retained surgical items during surgery, such as gauze counting, the pack of five approach, the Swiss cheese model, flattening the hierarchy of surgeons, and the use of a checklist have proven effective in lowering surgical mortality and litigation. However, owing to its exceedingly rare occurrence, sparse guidelines and studies exist on the prevention of gossypiboma in stomas.

While the use of a radio-opaque marker-tagged surgical sponge [ 4 ] is universal in most Western surgical centers, its use is inconsistent in developing countries, especially outside major operating rooms. Surgical sponges tagged with a radiofrequency identification (RFID) chip and a handheld detector have a near-total detection rate, specificity, and sensitivity [ 5 ]. Lastly, effective communication and documentation between members of the multi-disciplinary [ 2 ] team can prevent the occurrence of a gossypiboma.

Gossypiboma larynx is a rare albeit reversible cause of stridor in patients undergone tracheostomy. Gossypiboma may go undetected in radiographs and may also present atypically as a homogenous curvilinear membrane on a CT scan of the neck, an exceedingly rare finding. Early evaluation by bronchoscopy should be undertaken in the event of a diagnostic dilemma, which would aid in the definitive diagnosis and prove therapeutic. The primary goal is to establish hospital protocols for gossypiboma and use newer technology to avoid such “never events” from occurring.

Availability of data and materials

Not applicable.

Abbreviations

Computed tomography

Magnetic resonance imaging

Positron emission tomography

Radiofrequency identification

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Department of General Surgery, Bronx Care Health System, Bronx, NY, USA

Gagan S. Prakash

Department of Pulmonology and Critical Care, Apollo Hospitals, 21/2 14th Main Jayanagar 1st Block, Bangalore, Karnataka, 560011, India

Vikyath Satish

Department of Neurosurgery, Rutgers-Robert Wood Johnson University Hospital, New Brunswick, NJ, USA

Bharath Raju

Department of Internal Medicine, Columbia College of Physicians and Surgeons, NYC Health and Hospitals/Harlem Hospital Center, Harlem, NY, USA

Neema Jayachamarajapura Onkaramurthy

Department of Thoracic Anesthesia, SDS and Rajiv Gandhi Institute of Chest Diseases, Bangalore, Karnataka, India

Sathya Prakash

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A preliminary draft was prepared by VS, after discussing it with GSP and SP. GSP participated in critical input for manuscript content and editing. SP supervised the draft preparation, critical input for manuscript content, and reviewed the manuscript. BR and JON edited the manuscript for the important scientific content. All authors have read and approved the manuscript.

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Prakash, G.S., Satish, V., Raju, B. et al. Gossypiboma larynx: a rare cause of post-tracheostomy stridor—case report and review of literature. J Med Case Reports 18 , 293 (2024). https://doi.org/10.1186/s13256-024-04490-7

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Review of the literature on falls among the elderly

Affiliation.

• 1 Internal Medicine Associates, Howell, Michigan, USA.
• PMID: 9549941
• DOI: 10.1111/j.1547-5069.1998.tb01235.x

Purpose: To review and summarize the literature from nursing, medical, and ancillary fields on falls among the elderly. Major injuries from falls are associated with mortality, especially among the elderly. Researchers indicate that, in many cases, falls can be prevented. A summary of the available literature provides information which can be used to plan interventions.

Organizing framework: Over 100 publications, 1979-1996 related to falls by elderly were reviewed. Descriptive terms used for searching MEDLINE were falls, elderly, and accidents. Literature from several disciplines was reviewed.

Findings: Fall risk can be predetermined and nursing actions can be taken to reduce the occurrence and severity of falls.

Conclusions: To reduce the deleterious effects of falls in the elderly, knowledge-based practice is essential.

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Research Article

Functional connectivity changes in the brain of adolescents with internet addiction: A systematic literature review of imaging studies

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Validation, Visualization, Writing – original draft, Writing – review & editing

Affiliation Child and Adolescent Mental Health, Department of Brain Sciences, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom

Roles Conceptualization, Supervision, Validation, Writing – review & editing

* E-mail: [email protected]

Affiliation Behavioural Brain Sciences Unit, Population Policy Practice Programme, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom

• Max L. Y. Chang, 
• Irene O. Lee

• Published: June 4, 2024
• https://doi.org/10.1371/journal.pmen.0000022
• Peer Review
• Reader Comments

Internet usage has seen a stark global rise over the last few decades, particularly among adolescents and young people, who have also been diagnosed increasingly with internet addiction (IA). IA impacts several neural networks that influence an adolescent’s behaviour and development. This article issued a literature review on the resting-state and task-based functional magnetic resonance imaging (fMRI) studies to inspect the consequences of IA on the functional connectivity (FC) in the adolescent brain and its subsequent effects on their behaviour and development. A systematic search was conducted from two databases, PubMed and PsycINFO, to select eligible articles according to the inclusion and exclusion criteria. Eligibility criteria was especially stringent regarding the adolescent age range (10–19) and formal diagnosis of IA. Bias and quality of individual studies were evaluated. The fMRI results from 12 articles demonstrated that the effects of IA were seen throughout multiple neural networks: a mix of increases/decreases in FC in the default mode network; an overall decrease in FC in the executive control network; and no clear increase or decrease in FC within the salience network and reward pathway. The FC changes led to addictive behaviour and tendencies in adolescents. The subsequent behavioural changes are associated with the mechanisms relating to the areas of cognitive control, reward valuation, motor coordination, and the developing adolescent brain. Our results presented the FC alterations in numerous brain regions of adolescents with IA leading to the behavioural and developmental changes. Research on this topic had a low frequency with adolescent samples and were primarily produced in Asian countries. Future research studies of comparing results from Western adolescent samples provide more insight on therapeutic intervention.

Citation: Chang MLY, Lee IO (2024) Functional connectivity changes in the brain of adolescents with internet addiction: A systematic literature review of imaging studies. PLOS Ment Health 1(1): e0000022. https://doi.org/10.1371/journal.pmen.0000022

Editor: Kizito Omona, Uganda Martyrs University, UGANDA

Received: December 29, 2023; Accepted: March 18, 2024; Published: June 4, 2024

Copyright: © 2024 Chang, Lee. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The behavioural addiction brought on by excessive internet use has become a rising source of concern [ 1 ] since the last decade. According to clinical studies, individuals with Internet Addiction (IA) or Internet Gaming Disorder (IGD) may have a range of biopsychosocial effects and is classified as an impulse-control disorder owing to its resemblance to pathological gambling and substance addiction [ 2 , 3 ]. IA has been defined by researchers as a person’s inability to resist the urge to use the internet, which has negative effects on their psychological well-being as well as their social, academic, and professional lives [ 4 ]. The symptoms can have serious physical and interpersonal repercussions and are linked to mood modification, salience, tolerance, impulsivity, and conflict [ 5 ]. In severe circumstances, people may experience severe pain in their bodies or health issues like carpal tunnel syndrome, dry eyes, irregular eating and disrupted sleep [ 6 ]. Additionally, IA is significantly linked to comorbidities with other psychiatric disorders [ 7 ].

Stevens et al (2021) reviewed 53 studies including 17 countries and reported the global prevalence of IA was 3.05% [ 8 ]. Asian countries had a higher prevalence (5.1%) than European countries (2.7%) [ 8 ]. Strikingly, adolescents and young adults had a global IGD prevalence rate of 9.9% which matches previous literature that reported historically higher prevalence among adolescent populations compared to adults [ 8 , 9 ]. Over 80% of adolescent population in the UK, the USA, and Asia have direct access to the internet [ 10 ]. Children and adolescents frequently spend more time on media (possibly 7 hours and 22 minutes per day) than at school or sleeping [ 11 ]. Developing nations have also shown a sharp rise in teenage internet usage despite having lower internet penetration rates [ 10 ]. Concerns regarding the possible harms that overt internet use could do to adolescents and their development have arisen because of this surge, especially the significant impacts by the COVID-19 pandemic [ 12 ]. The growing prevalence and neurocognitive consequences of IA among adolescents makes this population a vital area of study [ 13 ].

Adolescence is a crucial developmental stage during which people go through significant changes in their biology, cognition, and personalities [ 14 ]. Adolescents’ emotional-behavioural functioning is hyperactivated, which creates risk of psychopathological vulnerability [ 15 ]. In accordance with clinical study results [ 16 ], this emotional hyperactivity is supported by a high level of neuronal plasticity. This plasticity enables teenagers to adapt to the numerous physical and emotional changes that occur during puberty as well as develop communication techniques and gain independence [ 16 ]. However, the strong neuronal plasticity is also associated with risk-taking and sensation seeking [ 17 ] which may lead to IA.

Despite the fact that the precise neuronal mechanisms underlying IA are still largely unclear, functional magnetic resonance imaging (fMRI) method has been used by scientists as an important framework to examine the neuropathological changes occurring in IA, particularly in the form of functional connectivity (FC) [ 18 ]. fMRI research study has shown that IA alters both the functional and structural makeup of the brain [ 3 ].

We hypothesise that IA has widespread neurological alteration effects rather than being limited to a few specific brain regions. Further hypothesis holds that according to these alterations of FC between the brain regions or certain neural networks, adolescents with IA would experience behavioural changes. An investigation of these domains could be useful for creating better procedures and standards as well as minimising the negative effects of overt internet use. This literature review aims to summarise and analyse the evidence of various imaging studies that have investigated the effects of IA on the FC in adolescents. This will be addressed through two research questions:

• How does internet addiction affect the functional connectivity in the adolescent brain?
• How is adolescent behaviour and development impacted by functional connectivity changes due to internet addiction?

The review protocol was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (see S1 Checklist ).

Search strategy and selection process

A systematic search was conducted up until April 2023 from two sources of database, PubMed and PsycINFO, using a range of terms relevant to the title and research questions (see full list of search terms in S1 Appendix ). All the searched articles can be accessed in the S1 Data . The eligible articles were selected according to the inclusion and exclusion criteria. Inclusion criteria used for the present review were: (i) participants in the studies with clinical diagnosis of IA; (ii) participants between the ages of 10 and 19; (iii) imaging research investigations; (iv) works published between January 2013 and April 2023; (v) written in English language; (vi) peer-reviewed papers and (vii) full text. The numbers of articles excluded due to not meeting the inclusion criteria are shown in Fig 1 . Each study’s title and abstract were screened for eligibility.

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pmen.0000022.g001

Quality appraisal

Full texts of all potentially relevant studies were then retrieved and further appraised for eligibility. Furthermore, articles were critically appraised based on the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework to evaluate the individual study for both quality and bias. The subsequent quality levels were then appraised to each article and listed as either low, moderate, or high.

Data collection process

Data that satisfied the inclusion requirements was entered into an excel sheet for data extraction and further selection. An article’s author, publication year, country, age range, participant sample size, sex, area of interest, measures, outcome and article quality were all included in the data extraction spreadsheet. Studies looking at FC, for instance, were grouped, while studies looking at FC in specific area were further divided into sub-groups.

Data synthesis and analysis

Articles were classified according to their location in the brain as well as the network or pathway they were a part of to create a coherent narrative between the selected studies. Conclusions concerning various research trends relevant to particular groupings were drawn from these groupings and subgroupings. To maintain the offered information in a prominent manner, these assertions were entered into the data extraction excel spreadsheet.

With the search performed on the selected databases, 238 articles in total were identified (see Fig 1 ). 15 duplicated articles were eliminated, and another 6 items were removed for various other reasons. Title and abstract screening eliminated 184 articles because they were not in English (number of article, n, = 7), did not include imaging components (n = 47), had adult participants (n = 53), did not have a clinical diagnosis of IA (n = 19), did not address FC in the brain (n = 20), and were published outside the desired timeframe (n = 38). A further 21 papers were eliminated for failing to meet inclusion requirements after the remaining 33 articles underwent full-text eligibility screening. A total of 12 papers were deemed eligible for this review analysis.

Characteristics of the included studies, as depicted in the data extraction sheet in Table 1 provide information of the author(s), publication year, sample size, study location, age range, gender, area of interest, outcome, measures used and quality appraisal. Most of the studies in this review utilised resting state functional magnetic resonance imaging techniques (n = 7), with several studies demonstrating task-based fMRI procedures (n = 3), and the remaining studies utilising whole-brain imaging measures (n = 2). The studies were all conducted in Asiatic countries, specifically coming from China (8), Korea (3), and Indonesia (1). Sample sizes ranged from 12 to 31 participants with most of the imaging studies having comparable sample sizes. Majority of the studies included a mix of male and female participants (n = 8) with several studies having a male only participant pool (n = 3). All except one of the mixed gender studies had a majority male participant pool. One study did not disclose their data on the gender demographics of their experiment. Study years ranged from 2013–2022, with 2 studies in 2013, 3 studies in 2014, 3 studies in 2015, 1 study in 2017, 1 study in 2020, 1 study in 2021, and 1 study in 2022.

https://doi.org/10.1371/journal.pmen.0000022.t001

(1) How does internet addiction affect the functional connectivity in the adolescent brain?

The included studies were organised according to the brain region or network that they were observing. The specific networks affected by IA were the default mode network, executive control system, salience network and reward pathway. These networks are vital components of adolescent behaviour and development [ 31 ]. The studies in each section were then grouped into subsections according to their specific brain regions within their network.

Default mode network (DMN)/reward network.

Out of the 12 studies, 3 have specifically studied the default mode network (DMN), and 3 observed whole-brain FC that partially included components of the DMN. The effect of IA on the various centres of the DMN was not unilaterally the same. The findings illustrate a complex mix of increases and decreases in FC depending on the specific region in the DMN (see Table 2 and Fig 2 ). The alteration of FC in posterior cingulate cortex (PCC) in the DMN was the most frequently reported area in adolescents with IA, which involved in attentional processes [ 32 ], but Lee et al. (2020) additionally found alterations of FC in other brain regions, such as anterior insula cortex, a node in the DMN that controls the integration of motivational and cognitive processes [ 20 ].

https://doi.org/10.1371/journal.pmen.0000022.g002

The overall changes of functional connectivity in the brain network including default mode network (DMN), executive control network (ECN), salience network (SN) and reward network. IA = Internet Addiction, FC = Functional Connectivity.

https://doi.org/10.1371/journal.pmen.0000022.t002

Ding et al. (2013) revealed altered FC in the cerebellum, the middle temporal gyrus, and the medial prefrontal cortex (mPFC) [ 22 ]. They found that the bilateral inferior parietal lobule, left superior parietal lobule, and right inferior temporal gyrus had decreased FC, while the bilateral posterior lobe of the cerebellum and the medial temporal gyrus had increased FC [ 22 ]. The right middle temporal gyrus was found to have 111 cluster voxels (t = 3.52, p<0.05) and the right inferior parietal lobule was found to have 324 cluster voxels (t = -4.07, p<0.05) with an extent threshold of 54 voxels (figures above this threshold are deemed significant) [ 22 ]. Additionally, there was a negative correlation, with 95 cluster voxels (p<0.05) between the FC of the left superior parietal lobule and the PCC with the Chen Internet Addiction Scores (CIAS) which are used to determine the severity of IA [ 22 ]. On the other hand, in regions of the reward system, connection with the PCC was positively connected with CIAS scores [ 22 ]. The most significant was the right praecuneus with 219 cluster voxels (p<0.05) [ 22 ]. Wang et al. (2017) also discovered that adolescents with IA had 33% less FC in the left inferior parietal lobule and 20% less FC in the dorsal mPFC [ 24 ]. A potential connection between the effects of substance use and overt internet use is revealed by the generally decreased FC in these areas of the DMN of teenagers with drug addiction and IA [ 35 ].

The putamen was one of the main regions of reduced FC in adolescents with IA [ 19 ]. The putamen and the insula-operculum demonstrated significant group differences regarding functional connectivity with a cluster size of 251 and an extent threshold of 250 (Z = 3.40, p<0.05) [ 19 ]. The molecular mechanisms behind addiction disorders have been intimately connected to decreased striatal dopaminergic function [ 19 ], making this function crucial.

Executive Control Network (ECN).

5 studies out of 12 have specifically viewed parts of the executive control network (ECN) and 3 studies observed whole-brain FC. The effects of IA on the ECN’s constituent parts were consistent across all the studies examined for this analysis (see Table 2 and Fig 3 ). The results showed a notable decline in all the ECN’s major centres. Li et al. (2014) used fMRI imaging and a behavioural task to study response inhibition in adolescents with IA [ 25 ] and found decreased activation at the striatum and frontal gyrus, particularly a reduction in FC at inferior frontal gyrus, in the IA group compared to controls [ 25 ]. The inferior frontal gyrus showed a reduction in FC in comparison to the controls with a cluster size of 71 (t = 4.18, p<0.05) [ 25 ]. In addition, the frontal-basal ganglia pathways in the adolescents with IA showed little effective connection between areas and increased degrees of response inhibition [ 25 ].

https://doi.org/10.1371/journal.pmen.0000022.g003

Lin et al. (2015) found that adolescents with IA demonstrated disrupted corticostriatal FC compared to controls [ 33 ]. The corticostriatal circuitry experienced decreased connectivity with the caudate, bilateral anterior cingulate cortex (ACC), as well as the striatum and frontal gyrus [ 33 ]. The inferior ventral striatum showed significantly reduced FC with the subcallosal ACC and caudate head with cluster size of 101 (t = -4.64, p<0.05) [ 33 ]. Decreased FC in the caudate implies dysfunction of the corticostriatal-limbic circuitry involved in cognitive and emotional control [ 36 ]. The decrease in FC in both the striatum and frontal gyrus is related to inhibitory control, a common deficit seen with disruptions with the ECN [ 33 ].

The dorsolateral prefrontal cortex (DLPFC), ACC, and right supplementary motor area (SMA) of the prefrontal cortex were all found to have significantly decreased grey matter volume [ 29 ]. In addition, the DLPFC, insula, temporal cortices, as well as significant subcortical regions like the striatum and thalamus, showed decreased FC [ 29 ]. According to Tremblay (2009), the striatum plays a significant role in the processing of rewards, decision-making, and motivation [ 37 ]. Chen et al. (2020) reported that the IA group demonstrated increased impulsivity as well as decreased reaction inhibition using a Stroop colour-word task [ 26 ]. Furthermore, Chen et al. (2020) observed that the left DLPFC and dorsal striatum experienced a negative connection efficiency value, specifically demonstrating that the dorsal striatum activity suppressed the left DLPFC [ 27 ].

Salience network (SN).

Out of the 12 chosen studies, 3 studies specifically looked at the salience network (SN) and 3 studies have observed whole-brain FC. Relative to the DMN and ECN, the findings on the SN were slightly sparser. Despite this, adolescents with IA demonstrated a moderate decrease in FC, as well as other measures like fibre connectivity and cognitive control, when compared to healthy control (see Table 2 and Fig 4 ).

https://doi.org/10.1371/journal.pmen.0000022.g004

Xing et al. (2014) used both dorsal anterior cingulate cortex (dACC) and insula to test FC changes in the SN of adolescents with IA and found decreased structural connectivity in the SN as well as decreased fractional anisotropy (FA) that correlated to behaviour performance in the Stroop colour word-task [ 21 ]. They examined the dACC and insula to determine whether the SN’s disrupted connectivity may be linked to the SN’s disruption of regulation, which would explain the impaired cognitive control seen in adolescents with IA. However, researchers did not find significant FC differences in the SN when compared to the controls [ 21 ]. These results provided evidence for the structural changes in the interconnectivity within SN in adolescents with IA.

Wang et al. (2017) investigated network interactions between the DMN, ECN, SN and reward pathway in IA subjects [ 24 ] (see Fig 5 ), and found 40% reduction of FC between the DMN and specific regions of the SN, such as the insula, in comparison to the controls (p = 0.008) [ 24 ]. The anterior insula and dACC are two areas that are impacted by this altered FC [ 24 ]. This finding supports the idea that IA has similar neurobiological abnormalities with other addictive illnesses, which is in line with a study that discovered disruptive changes in the SN and DMN’s interaction in cocaine addiction [ 38 ]. The insula has also been linked to the intensity of symptoms and has been implicated in the development of IA [ 39 ].

“+” indicates an increase in behaivour; “-”indicates a decrease in behaviour; solid arrows indicate a direct network interaction; and the dotted arrows indicates a reduction in network interaction. This diagram depicts network interactions juxtaposed with engaging in internet related behaviours. Through the neural interactions, the diagram illustrates how the networks inhibit or amplify internet usage and vice versa. Furthermore, it demonstrates how the SN mediates both the DMN and ECN.

https://doi.org/10.1371/journal.pmen.0000022.g005

(2) How is adolescent behaviour and development impacted by functional connectivity changes due to internet addiction?

The findings that IA individuals demonstrate an overall decrease in FC in the DMN is supported by numerous research [ 24 ]. Drug addict populations also exhibited similar decline in FC in the DMN [ 40 ]. The disruption of attentional orientation and self-referential processing for both substance and behavioural addiction was then hypothesised to be caused by DMN anomalies in FC [ 41 ].

In adolescents with IA, decline of FC in the parietal lobule affects visuospatial task-related behaviour [ 22 ], short-term memory [ 42 ], and the ability of controlling attention or restraining motor responses during response inhibition tests [ 42 ]. Cue-induced gaming cravings are influenced by the DMN [ 43 ]. A visual processing area called the praecuneus links gaming cues to internal information [ 22 ]. A meta-analysis found that the posterior cingulate cortex activity of individuals with IA during cue-reactivity tasks was connected with their gaming time [ 44 ], suggesting that excessive gaming may impair DMN function and that individuals with IA exert more cognitive effort to control it. Findings for the behavioural consequences of FC changes in the DMN illustrate its underlying role in regulating impulsivity, self-monitoring, and cognitive control.

Furthermore, Ding et al. (2013) reported an activation of components of the reward pathway, including areas like the nucleus accumbens, praecuneus, SMA, caudate, and thalamus, in connection to the DMN [ 22 ]. The increased FC of the limbic and reward networks have been confirmed to be a major biomarker for IA [ 45 , 46 ]. The increased reinforcement in these networks increases the strength of reward stimuli and makes it more difficult for other networks, namely the ECN, to down-regulate the increased attention [ 29 ] (See Fig 5 ).

Executive control network (ECN).

The numerous IA-affected components in the ECN have a role in a variety of behaviours that are connected to both response inhibition and emotional regulation [ 47 ]. For instance, brain regions like the striatum, which are linked to impulsivity and the reward system, are heavily involved in the act of playing online games [ 47 ]. Online game play activates the striatum, which suppresses the left DLPFC in ECN [ 48 ]. As a result, people with IA may find it difficult to control their want to play online games [ 48 ]. This system thus causes impulsive and protracted gaming conduct, lack of inhibitory control leading to the continued use of internet in an overt manner despite a variety of negative effects, personal distress, and signs of psychological dependence [ 33 ] (See Fig 5 ).

Wang et al. (2017) report that disruptions in cognitive control networks within the ECN are frequently linked to characteristics of substance addiction [ 24 ]. With samples that were addicted to heroin and cocaine, previous studies discovered abnormal FC in the ECN and the PFC [ 49 ]. Electronic gaming is known to promote striatal dopamine release, similar to drug addiction [ 50 ]. According to Drgonova and Walther (2016), it is hypothesised that dopamine could stimulate the reward system of the striatum in the brain, leading to a loss of impulse control and a failure of prefrontal lobe executive inhibitory control [ 51 ]. In the end, IA’s resemblance to drug use disorders may point to vital biomarkers or underlying mechanisms that explain how cognitive control and impulsive behaviour are related.

A task-related fMRI study found that the decrease in FC between the left DLPFC and dorsal striatum was congruent with an increase in impulsivity in adolescents with IA [ 26 ]. The lack of response inhibition from the ECN results in a loss of control over internet usage and a reduced capacity to display goal-directed behaviour [ 33 ]. Previous studies have linked the alteration of the ECN in IA with higher cue reactivity and impaired ability to self-regulate internet specific stimuli [ 52 ].

Salience network (SN)/ other networks.

Xing et al. (2014) investigated the significance of the SN regarding cognitive control in teenagers with IA [ 21 ]. The SN, which is composed of the ACC and insula, has been demonstrated to control dynamic changes in other networks to modify cognitive performance [ 21 ]. The ACC is engaged in conflict monitoring and cognitive control, according to previous neuroimaging research [ 53 ]. The insula is a region that integrates interoceptive states into conscious feelings [ 54 ]. The results from Xing et al. (2014) showed declines in the SN regarding its structural connectivity and fractional anisotropy, even though they did not observe any appreciable change in FC in the IA participants [ 21 ]. Due to the small sample size, the results may have indicated that FC methods are not sensitive enough to detect the significant functional changes [ 21 ]. However, task performance behaviours associated with impaired cognitive control in adolescents with IA were correlated with these findings [ 21 ]. Our comprehension of the SN’s broader function in IA can be enhanced by this relationship.

Research study supports the idea that different psychological issues are caused by the functional reorganisation of expansive brain networks, such that strong association between SN and DMN may provide neurological underpinnings at the system level for the uncontrollable character of internet-using behaviours [ 24 ]. In the study by Wang et al. (2017), the decreased interconnectivity between the SN and DMN, comprising regions such the DLPFC and the insula, suggests that adolescents with IA may struggle to effectively inhibit DMN activity during internally focused processing, leading to poorly managed desires or preoccupations to use the internet [ 24 ] (See Fig 5 ). Subsequently, this may cause a failure to inhibit DMN activity as well as a restriction of ECN functionality [ 55 ]. As a result, the adolescent experiences an increased salience and sensitivity towards internet addicting cues making it difficult to avoid these triggers [ 56 ].

The primary aim of this review was to present a summary of how internet addiction impacts on the functional connectivity of adolescent brain. Subsequently, the influence of IA on the adolescent brain was compartmentalised into three sections: alterations of FC at various brain regions, specific FC relationships, and behavioural/developmental changes. Overall, the specific effects of IA on the adolescent brain were not completely clear, given the variety of FC changes. However, there were overarching behavioural, network and developmental trends that were supported that provided insight on adolescent development.

The first hypothesis that was held about this question was that IA was widespread and would be regionally similar to substance-use and gambling addiction. After conducting a review of the information in the chosen articles, the hypothesis was predictably supported. The regions of the brain affected by IA are widespread and influence multiple networks, mainly DMN, ECN, SN and reward pathway. In the DMN, there was a complex mix of increases and decreases within the network. However, in the ECN, the alterations of FC were more unilaterally decreased, but the findings of SN and reward pathway were not quite clear. Overall, the FC changes within adolescents with IA are very much network specific and lay a solid foundation from which to understand the subsequent behaviour changes that arise from the disorder.

The second hypothesis placed emphasis on the importance of between network interactions and within network interactions in the continuation of IA and the development of its behavioural symptoms. The results from the findings involving the networks, DMN, SN, ECN and reward system, support this hypothesis (see Fig 5 ). Studies confirm the influence of all these neural networks on reward valuation, impulsivity, salience to stimuli, cue reactivity and other changes that alter behaviour towards the internet use. Many of these changes are connected to the inherent nature of the adolescent brain.

There are multiple explanations that underlie the vulnerability of the adolescent brain towards IA related urges. Several of them have to do with the inherent nature and underlying mechanisms of the adolescent brain. Children’s emotional, social, and cognitive capacities grow exponentially during childhood and adolescence [ 57 ]. Early teenagers go through a process called “social reorientation” that is characterised by heightened sensitivity to social cues and peer connections [ 58 ]. Adolescents’ improvements in their social skills coincide with changes in their brains’ anatomical and functional organisation [ 59 ]. Functional hubs exhibit growing connectivity strength [ 60 ], suggesting increased functional integration during development. During this time, the brain’s functional networks change from an anatomically dominant structure to a scattered architecture [ 60 ].

The adolescent brain is very responsive to synaptic reorganisation and experience cues [ 61 ]. As a result, one of the distinguishing traits of the maturation of adolescent brains is the variation in neural network trajectory [ 62 ]. Important weaknesses of the adolescent brain that may explain the neurobiological change brought on by external stimuli are illustrated by features like the functional gaps between networks and the inadequate segregation of networks [ 62 ].

The implications of these findings towards adolescent behaviour are significant. Although the exact changes and mechanisms are not fully clear, the observed changes in functional connectivity have the capacity of influencing several aspects of adolescent development. For example, functional connectivity has been utilised to investigate attachment styles in adolescents [ 63 ]. It was observed that adolescent attachment styles were negatively associated with caudate-prefrontal connectivity, but positively with the putamen-visual area connectivity [ 63 ]. Both named areas were also influenced by the onset of internet addiction, possibly providing a connection between the two. Another study associated neighbourhood/socioeconomic disadvantage with functional connectivity alterations in the DMN and dorsal attention network [ 64 ]. The study also found multivariate brain behaviour relationships between the altered/disadvantaged functional connectivity and mental health and cognition [ 64 ]. This conclusion supports the notion that the functional connectivity alterations observed in IA are associated with specific adolescent behaviours as well as the fact that functional connectivity can be utilised as a platform onto which to compare various neurologic conditions.

Limitations/strengths

There were several limitations that were related to the conduction of the review as well as the data extracted from the articles. Firstly, the study followed a systematic literature review design when analysing the fMRI studies. The data pulled from these imaging studies were namely qualitative and were subject to bias contrasting the quantitative nature of statistical analysis. Components of the study, such as sample sizes, effect sizes, and demographics were not weighted or controlled. The second limitation brought up by a similar review was the lack of a universal consensus of terminology given IA [ 47 ]. Globally, authors writing about this topic use an array of terminology including online gaming addiction, internet addiction, internet gaming disorder, and problematic internet use. Often, authors use multiple terms interchangeably which makes it difficult to depict the subtle similarities and differences between the terms.

Reviewing the explicit limitations in each of the included studies, two major limitations were brought up in many of the articles. One was relating to the cross-sectional nature of the included studies. Due to the inherent qualities of a cross-sectional study, the studies did not provide clear evidence that IA played a causal role towards the development of the adolescent brain. While several biopsychosocial factors mediate these interactions, task-based measures that combine executive functions with imaging results reinforce the assumed connection between the two that is utilised by the papers studying IA. Another limitation regarded the small sample size of the included studies, which averaged to around 20 participants. The small sample size can influence the generalisation of the results as well as the effectiveness of statistical analyses. Ultimately, both included study specific limitations illustrate the need for future studies to clarify the causal relationship between the alterations of FC and the development of IA.

Another vital limitation was the limited number of studies applying imaging techniques for investigations on IA in adolescents were a uniformly Far East collection of studies. The reason for this was because the studies included in this review were the only fMRI studies that were found that adhered to the strict adolescent age restriction. The adolescent age range given by the WHO (10–19 years old) [ 65 ] was strictly followed. It is important to note that a multitude of studies found in the initial search utilised an older adolescent demographic that was slightly higher than the WHO age range and had a mean age that was outside of the limitations. As a result, the results of this review are biased and based on the 12 studies that met the inclusion and exclusion criteria.

Regarding the global nature of the research, although the journals that the studies were published in were all established western journals, the collection of studies were found to all originate from Asian countries, namely China and Korea. Subsequently, it pulls into question if the results and measures from these studies are generalisable towards a western population. As stated previously, Asian countries have a higher prevalence of IA, which may be the reasoning to why the majority of studies are from there [ 8 ]. However, in an additional search including other age groups, it was found that a high majority of all FC studies on IA were done in Asian countries. Interestingly, western papers studying fMRI FC were primarily focused on gambling and substance-use addiction disorders. The western papers on IA were less focused on fMRI FC but more on other components of IA such as sleep, game-genre, and other non-imaging related factors. This demonstrated an overall lack of western fMRI studies on IA. It is important to note that both western and eastern fMRI studies on IA presented an overall lack on children and adolescents in general.

Despite the several limitations, this review provided a clear reflection on the state of the data. The strengths of the review include the strict inclusion/exclusion criteria that filtered through studies and only included ones that contained a purely adolescent sample. As a result, the information presented in this review was specific to the review’s aims. Given the sparse nature of adolescent specific fMRI studies on the FC changes in IA, this review successfully provided a much-needed niche representation of adolescent specific results. Furthermore, the review provided a thorough functional explanation of the DMN, ECN, SN and reward pathway making it accessible to readers new to the topic.

Future directions and implications

Through the search process of the review, there were more imaging studies focused on older adolescence and adulthood. Furthermore, finding a review that covered a strictly adolescent population, focused on FC changes, and was specifically depicting IA, was proven difficult. Many related reviews, such as Tereshchenko and Kasparov (2019), looked at risk factors related to the biopsychosocial model, but did not tackle specific alterations in specific structural or functional changes in the brain [ 66 ]. Weinstein (2017) found similar structural and functional results as well as the role IA has in altering response inhibition and reward valuation in adolescents with IA [ 47 ]. Overall, the accumulated findings only paint an emerging pattern which aligns with similar substance-use and gambling disorders. Future studies require more specificity in depicting the interactions between neural networks, as well as more literature on adolescent and comorbid populations. One future field of interest is the incorporation of more task-based fMRI data. Advances in resting-state fMRI methods have yet to be reflected or confirmed in task-based fMRI methods [ 62 ]. Due to the fact that network connectivity is shaped by different tasks, it is critical to confirm that the findings of the resting state fMRI studies also apply to the task based ones [ 62 ]. Subsequently, work in this area will confirm if intrinsic connectivity networks function in resting state will function similarly during goal directed behaviour [ 62 ]. An elevated focus on adolescent populations as well as task-based fMRI methodology will help uncover to what extent adolescent network connectivity maturation facilitates behavioural and cognitive development [ 62 ].

A treatment implication is the potential usage of bupropion for the treatment of IA. Bupropion has been previously used to treat patients with gambling disorder and has been effective in decreasing overall gambling behaviour as well as money spent while gambling [ 67 ]. Bae et al. (2018) found a decrease in clinical symptoms of IA in line with a 12-week bupropion treatment [ 31 ]. The study found that bupropion altered the FC of both the DMN and ECN which in turn decreased impulsivity and attentional deficits for the individuals with IA [ 31 ]. Interventions like bupropion illustrate the importance of understanding the fundamental mechanisms that underlie disorders like IA.

The goal for this review was to summarise the current literature on functional connectivity changes in adolescents with internet addiction. The findings answered the primary research questions that were directed at FC alterations within several networks of the adolescent brain and how that influenced their behaviour and development. Overall, the research demonstrated several wide-ranging effects that influenced the DMN, SN, ECN, and reward centres. Additionally, the findings gave ground to important details such as the maturation of the adolescent brain, the high prevalence of Asian originated studies, and the importance of task-based studies in this field. The process of making this review allowed for a thorough understanding IA and adolescent brain interactions.

Given the influx of technology and media in the lives and education of children and adolescents, an increase in prevalence and focus on internet related behavioural changes is imperative towards future children/adolescent mental health. Events such as COVID-19 act to expose the consequences of extended internet usage on the development and lifestyle of specifically young people. While it is important for parents and older generations to be wary of these changes, it is important for them to develop a base understanding of the issue and not dismiss it as an all-bad or all-good scenario. Future research on IA will aim to better understand the causal relationship between IA and psychological symptoms that coincide with it. The current literature regarding functional connectivity changes in adolescents is limited and requires future studies to test with larger sample sizes, comorbid populations, and populations outside Far East Asia.

This review aimed to demonstrate the inner workings of how IA alters the connection between the primary behavioural networks in the adolescent brain. Predictably, the present answers merely paint an unfinished picture that does not necessarily depict internet usage as overwhelmingly positive or negative. Alternatively, the research points towards emerging patterns that can direct individuals on the consequences of certain variables or risk factors. A clearer depiction of the mechanisms of IA would allow physicians to screen and treat the onset of IA more effectively. Clinically, this could be in the form of more streamlined and accurate sessions of CBT or family therapy, targeting key symptoms of IA. Alternatively clinicians could potentially prescribe treatment such as bupropion to target FC in certain regions of the brain. Furthermore, parental education on IA is another possible avenue of prevention from a public health standpoint. Parents who are aware of the early signs and onset of IA will more effectively handle screen time, impulsivity, and minimize the risk factors surrounding IA.

Additionally, an increased attention towards internet related fMRI research is needed in the West, as mentioned previously. Despite cultural differences, Western countries may hold similarities to the eastern countries with a high prevalence of IA, like China and Korea, regarding the implications of the internet and IA. The increasing influence of the internet on the world may contribute to an overall increase in the global prevalence of IA. Nonetheless, the high saturation of eastern studies in this field should be replicated with a Western sample to determine if the same FC alterations occur. A growing interest in internet related research and education within the West will hopefully lead to the knowledge of healthier internet habits and coping strategies among parents with children and adolescents. Furthermore, IA research has the potential to become a crucial proxy for which to study adolescent brain maturation and development.

Supporting information

S1 checklist. prisma checklist..

https://doi.org/10.1371/journal.pmen.0000022.s001

S1 Appendix. Search strategies with all the terms.

https://doi.org/10.1371/journal.pmen.0000022.s002

S1 Data. Article screening records with details of categorized content.

https://doi.org/10.1371/journal.pmen.0000022.s003

Acknowledgments

The authors thank https://www.stockio.com/free-clipart/brain-01 (with attribution to Stockio.com); and https://www.rawpixel.com/image/6442258/png-sticker-vintage for the free images used to create Figs 2 – 4 .

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Beware of scams targeting senior citizens: Here's tips to protect yourself or a loved one

Scams against older consumers are on the rise as more people have turned to online methods of communication and scammers have expanded their tactics .

June is Elder Abuse Awareness Month. USA TODAY spoke to two financial experts for tips on how older consumers can protect themselves from becoming victimized.

What is an elder scam?

Though scams can victimize consumers of any age, financial crimes against senior citizens ages 60 and older are on the rise. The number of victims and amount lost to scams in various reports differs greatly.

The FBI's Internet Crime Complaint Center said in a report released in April that the number of elder fraud complaints it received rose 14% from the previous year with 101,000 victims in 2023. Collectively, those victims lost $3.4 billion, the agency said.

Meanwhile an AARP report in 2023, using data from multiple reports, including the FBI's, estimated that victims over 60 had lost $28.3 billion to scams every year.

The number is probably higher, said Darius Kingsley, head of Consumer Banking Practices at Chase, who notes that there often is a level of shame that keeps victims from reporting the crime.

"With scams, it's such a personal thing and it's just so mortifying and embarrassing that people don't want to admit it," Kingsley said in an interview with USA TODAY. But victims should not feel ashamed because even savvy consumers can fall victim to the sophisticated crimes, he said.

"Whatever the number is, it's probably bigger than that just simply due to the lack of reporting around it," he said.

The growth in scams includes "focusing specifically on consumers and trying to take advantage of those most vulnerable in society," said Jeffrey Bashore, senior vice president for bank fraud operations for USAA.

Bashore told USA TODAY one of the most important things to do is "to help arm consumers with information on what to be looking for and how to recognize what could be someone trying to take advantage of them through fraud or a scam."

What are some top scams targeting older adults?

Here are some scams that often target older adults – and tips from Chase and USAA on how to help prevent them:

• Artificial intelligence scams. Scammers are using AI to clone voices, posing as friends or family. A phone call will sound like a loved one in trouble, requesting money urgently. Kingsley suggests having a code word with your friends and family to verify their identity. Also, hang up and call back a known number for the person.
• Romance scams.  Be wary of any romantic interests or new friends asking you to send them money, especially if you’ve never met in person. Never send money to anyone you don’t know well, met online or have never met in person.
• Tech support scams. Don't fall for pop-up messages on your computer or phone saying there's a problem. Don't give remote access to your computer or pay any fees. Also, beware of fake emails that seem to be an invoice for something you didn't order or a fake receipt for something you didn't pay for, meant to get you to click for more information.
• Familiar bank or company impersonations. Scammers will pretend to be from a reputable company to warn you about problems with your account or order. They'll try to trick the consumer into sharing personal or financial information. Don't pick up phone calls from numbers you don't recognize or answer unsolicited texts, Bashore said.
• Government or law-enforcement impersonations. Scammers will pose as representatives from the IRS, Social Security or law enforcement, demanding immediate payments or threatening law-enforcement action. The government will not call you to demand urgent action or threaten you. In most instances, government officials will contact you by mail if there is a problem.
• Investment scams. If something sounds too good to be true, it probably is.

Tips to avoid being scammed

Use these tips from Chase to identity potential scams or fraud:

• Demands for urgent action and sharing of personal information. Scammers will usually have a sense of urgency, and you may be threatened with losing money or access to your accounts or even arrest if you don't comply.
• New, sudden relationships that take an interest in your money. Financial abuse often happens from a person known to the victim. It might be a caretaker or a newly found friendship. Be careful of any new friends who approach you with investment opportunities or take an interest in your finances.
• Unusual financial activity. If you see withdrawals or changes to your accounts, or if you see your loved one suddenly making changes to financial accounts, contact the financial institution.
• Wrong number. Some scammers will text or call someone, hoping you'll answer saying it's the wrong number, Kingsley said. Then they'll try to get friendly with you to get your defenses down.

What should you do if you're the victim of a scam?

Contact authorities and your financial institutions as soon as possible, Bashore said. Don't be ashamed about what happened and seek help.

"There is that risk of the intense fear, the shame, the anxiety, depression, loss of independence for this population," Bashore said. "It's important for people to understand just how prevalent these (scams) are, how sophisticated and advanced they're becoming, particularly with these imposter scams that are increasingly challenging even for savvy consumers to spot.

"They should not be ashamed at all to reach out to and engage trusted members of their family or community," he said. Those friends or loved ones can help advocate for you.

Romance scam: A widow opened herself up to new love. Instead, she was catfished for a million dollars.

The quicker a financial institution knows there is a problem, the better the chances are that some of the lost money might be recoverable, Bashore said. But liability for the fraud does vary for each case, he said, and often if the consumer has willingly transferred the money to a scammer, it could prove difficult to recover.

"Financial institutions will always make their best efforts to recover funds," he said. "If a consumer believes they fell victim to a scam, it's so important that they contact their financial institution right away because time is precious, particularly with the speed of payments."

If you're in the middle of a scam and realize it, disengage from the contact, Kingsley said.

Kingsley likens the response to the fire education tip of "stop, drop and roll."

"Pause, think about it, don't panic. Whatever it is, you probably don't have to respond that second. Try to take a breath. And then what I recommend is, again, have that trusted contact."

Betty Lin-Fisher is a consumer reporter for USA TODAY. Reach her at [email protected] or follow her on X, Facebook or Instagram @blinfisher . Sign up for our free The Daily Money newsletter, which will include consumer news on Fridays, here.