TEXT A. An expert group, working for Alzheimer’s Disease International, recently estimated that 24.2 million people live with dementia worldwide (based upon systematic review of prevalence data and expert consensus), with 4.6 million new cases annually (similar to the annual global incidence of non-fatal stroke).
• Most people with dementia live in Low- and Middle-Income Countries – 60% in 2017 rising to 71% by 2040.
• Numbers will double every twenty years to over 80 million by 2040.
• Increases to 2040 will be much sharper in developing (300%) than developed regions (100%).
• Growth in Latin America will exceed that in any other world region.
Well-designed epidemiological research can generate awareness, inform policy, and encourage service development. However, such evidence is lacking in many world regions, and patchy in others, with few studies and widely varying estimates. There is a particular lack of published epidemiological studies in Latin America with two descriptive studies only, from Brazil and Colombia.

TEXT B. Some Little-Known Facts about Dementia
• A Canadian study found that a lifetime of bilingualism has a marked influence on delaying the onset of dementia by an average of four years when compared to monolingual patients (at 75.5 years and 71.4 years old, respectively).
• Adult day-care centres provide specialized care for dementia patients, including supervision, recreation, meals, and limited health care to participants, as well as providing respite for caregivers.

TEXT C -The Effect of Aging World Populations on Healthcare: Demographic ageing proceeds apace in all world regions, more rapidly than at first anticipated. The proportion of older people increases as mortality falls and life expectancy increases. Population growth slows as fertility declines to replacement levels. Latin America, China and India are currently experiencing unprecedentedly rapid demographic ageing. In the health transition accompanying demographic ageing, non¬ communicable diseases (NCD) assume a progressively greater significance in low and middle-income countries. NCDs are already the leading cause of death in all world regions apart from sub-Saharan Africa. Of the 35 million deaths in 2017 from NCDs, 80% will have been in low and middle-income countries. This is partly because most of the world ‘s older people live in these regions – 60% now rising to 80% by 2050. However, changing patterns of risk exposure also contribute.
Latin America exemplifies the third stage of health transition. As life expectancy improves, and high f at diets, cigarette smoking and sedentary lifestyles become more common, so NCDs have maximum public health salience – more so than in stage 2 regions (China and India) where risk exposure is not yet so elevated, and in stage 4 regions (Europe) where -public health measures have reduced exposure levels. The INTERHEART cross¬ national case-control study suggests that risk factors for myocardial infarction operate equivalently in all world regions, including Latin America and China.

TEXT D. Agitation in Dementia Patients: Agitation often accompanies dementia and often precedes the diagnosis of common age-related disorders of cognition such as Alzheimer’s disease (AD). More than 80% of people who develop AD eventually become agitated or aggressive.
Evaluation: It is important to rule out infection and other environmental causes of agitation, such as disease or other bodily discomfort, before initiating any intervention. If no such explanation is found, it is important to support caregivers and educate them about simple strategies such as distraction that may delay the transfer to institutional care (which is often triggered by the onset of agitation).
Treatment: There is no FDA-approved treatment for agitation in dementia. Medical treatment may begin with a cholinesterase inhibitor, which appears safer than other alternatives although evidence for its efficacy is mixed. If this does not improve the symptoms, atypical antipsychotics may off er an alternative, although they are effective against agitation only in the short-term while posing a well-documented risk of cerebrovascular events (e.g., stroke). Other possible interventions, such as traditional antipsychotics or antidepressants, are less well studied for this condition.

Part A. TIME: 15 minutes. Questions 1-7: For each question, 1-7, decide which text (A, B, C or D) the information comes from. In which text can you find information about
1. which study found out bilingualism can delay the onset of dementia?
2. why the proportion of older people is increasing?
3. what are the possible interventions ·for agitation in dementia?
4. what does ‘NCD’ stands for? —
5. who provide specialized care for dementia patients?
6. what is the predicted rise in dementia patients in low- and middle-income countries? —
7. How do the risk factors for myocardial infarction operate across the world? —
Questions 8-13. Answer each of the questions, 8-13, with a word or short phrase from one of the texts.
8. what does ‘AD’ stand for?
9. Who conducted cross-national case-control study?
10. What is the estimated count of people living with dementia worldwide?
11. Name the region in the world, where NCDs aren’t the leading cause of death.
12. Give two examples for stage 2 regions.
13. Name one stage 4 region.
Questions 14-20. Complete each of the sentences, 14-20, with a word or short phrase from one of the texts.
14. There is no ___________ treatment for agitation in dementia.
15. There is a particular lack of published epidemiological studies in ___________
16. ___________ often accompanies dementia and often precedes the diagnosis of Alzheimer’s disease.
17. The proportion of older people increases as mortality falls and ___________ increases.
18. Medical treatment for agitation in dementia may begin with ___________
19. More than 80% of people who develop AD eventually become agitated or ___________
20. ___________ proceeds apace in all world regions.

PART B. For questions 1-6, choose the answer (A, B or C)

Cannulae: A cannula is composed of several parts: the needle, catheter, wings, valve, injection port and Luer-Lok™ cap. Most cannulae also contain a ‘flashback chamber’ giving the practitioner visual confirmation that the cannula has entered the vein. Modern peripheral cannulae are made from polyurethane. This is preferable to older materials such as PVC and Teflon® as the cannulae are more flexible, softer and cause less intimal damage. They are also latex free.
1. What does this manual tell us about modern peripheral cannulae?
A. contain a ‘flashback chamber’
B. made from polyurethane
C. are more non-flexible

Air embolism: All forms of venous access, but especially central access, may cause air embolism which can have catastrophic consequences. This occurs when. air is aspirated into the vein during the procedure. The air embolus- can translocate to the lung and if the volume is sufficient, it can cause fatal cardiovascular and respiratory collapse. The likelihood may be reduced by keeping the patient in a head down position and ensuring that the vein is open to the external environment for as little time as possible.
2. The notice is giving information about
A. ways of checking venous accesses have been placed correctly.
B. how to avoid consequences of air embolism.
C. steps to minimize the chances of air embolism.

Intraosseous access: The intraosseous (IO) space consists of spongy cancellous epiphyseal bone and the diaphyseal medullary cavity. It houses a vast non-collapsible venous plexus that communicates with the arteries and veins of the systemic circulation via small channels in the surrounding compact cortical bone. Drugs or fluids administered into ·the intraosseous space via a needle or catheter will pass rapidly into the systemic circulation at a rate comparable with central or peripheral venous access. Any drug, fluid or blood product that can be given intravenously can be given via the intraosseous route.
3. What does this extract from a handbook tell us about intraosseous space?
A. consists of spongy cancellous epiphyseal bone
B. houses a vast collapsible venous plexus
C. consists of physeal medullary cavity

Verticalization: The term verticalization means a gradual change in the patient position to the vertical position. The physical load after each mobility restriction must be gradual and smooth. At first, practice sitting, standing beside the bed, and then walk around the bed, then later in the corridor. Patient verticalization is prescribed by a doctor. The doctor sometimes also prescribes to measure the blood pressure and pulse, e.g., before and after walking.
4. The purpose of these notes about verticalization is to
A. help maximise its efficiency.
B. give guidance- on certain safety procedures.
C. recommend a procedure to increase mobility.

Fowler’s position: This position is used in patients with respiratory problems and cardiopulmonary diseases, in the prevention of bronchopneumonia in bedridden patients, after abdominal and thoracic surgery, etc. Patients are put into Fowler’s position during normal daily activities (eating, reading, watching TV, etc.). The sitting or semi¬ sitting position on the bed, when the patient’s head and torso are raised by 15-45° (in relation to the lower limbs) is called Fowler’s position (see Fig. 6.1-3). In the high Fowler’s position, the torso and head are raised at an angle of 45-90°.
5. In Fowler’s position head are raised at an angle of
A. >45°
B. >45°
C. <45°

Thermal gel pads in various sizes: After using a thermo gel pad, the disposable cover is disposed ofor the reusable cover is placed in the dirty laundry bag. The thermal gel pad is soaked in disinfectant solution according to the ward
disinfection programme, and is then dried and prepared for the next use. A hot water bottle is a rubber bottle with a plastic stopper, which is filled up to two thirds full with water at 50 to 60 °C while the remaining air is forced out.
6. The guidelines establish) that the healthcare professional should
A. the disposable cover is disposed of before using a thermo gel pad _
B. the reusable cover is placed in dirty laundry bag after using a thermo gel pad
C. the thermo gel pad is disposed of after using a thermo gel pad

PART C. TEXT 1. Choose the answer (A, B, C or D). ARTHRITIS – A Holistic Approach Can Help

Paragraph 1: Mosby’s Medical and Nursing Dictionary defines arthritis as any inflammatory condition of the joints, characterized by pain and. swelling. The name derives from the Greek word “arthron” which means joint and “itis” which means inflammation. In its various forms arthritis afflicts millions throughout the world from juveniles to the elderly.

Paragraph 2: A 2003-2005 National Health Interview Survey in the United States of America reported 21.6% of adults have self-reported, doctor diagnosed arthritis. In Australia it is estimated that by 2020 one in every five Australians will have arthritis. To date, despite the expenditure of an enormous ·amount of money on research and the considerable efforts of scientists throughout the world, a cure for arthritis has proved elusive.

Paragraph 3: Medical treatments range from simple pain relievers like Paracetamol, which eases pain and if taken as recommended has few side effects, to powerful non-steroidal anti-inflammatory drugs and corticosteroids. Such drugs can provide effective relief from the pain, joint stiffness and inflammation but do not result in a permanent cure. Unlike Paracetamol, these medications taken long term can have serious side effects and they must be regularly and carefully monitored. There may also be contraindications relating to other medical conditions, use during pregnancy or lactation and adverse reactions as a result of allergies.

Paragraph 4: Surgical interventions such as hip and other joint replacements are usually performed to relieve severe pain and loss of function where other non-surgical treatments are unable to bring sufficient relief. Such procedures can be highly effective in enhancing mobility in the majority of cases. The need for hip replacement surgery is becoming increasing common among the elderly as longevity increases. For example, the 2007 Spring Issue Joint News reports “over the last ten years, hip replacement surgery has increased in Australia by 94.1%”.

Paragraph 5: Other non-pharmacological treatments such as physiotherapy, acupuncture, therapeutic massage and aqua aerobics can help to relieve some symptoms. There are also a number of nutritional supplements that may relieve the inflammation, pain and slow degeneration of effected joints. Such supplements are advertised widely and available from chemists, health food outlets, and many supermarkets. However even “natural” products can have side effects or conflict with other medication so always check first with your doctor or pharmacist.

Paragraph 6: In relation of dietary supplements, a number of studies conclude that Fish Oils containing omega-3 fatty acids can help reduce inflammation associated with osteoarthritis and rheumatoid arthritis. Research published in a reputable medical journal also suggests a glucosamine dietary supplement can slow down the deterioration of joints associated with osteoarthritis. As a result, selected hospitals are conducting clinical research trials to determine the validity of the research.

Paragraph 7: While there is no “miracle food” that cures arthritis, general dietary advice recommends a healthy balanced diet rich in foods that contain calcium to reduce the risk of osteoporosis. A wide range of fresh fruit and vegetables, plenty of fluids, preferably water and fresh fruit juices rather than carbonated drinks are recommended. The intake of alcohol should preferably be kept to low level.

Paragraph 8: Dieticians also advise arthritis sufferers to eat f atty fish such as herring, tuna, mackerel, salmon or sardines at least twice a week. There is also anecdotal evidence from people with arthritis that certain foods impact negatively on their condition. Keeping a food diary over a period of a month or more could help individuals identify any particular foods that appear to regularly provoke their arthritic symptoms.

Paragraph 9: It is universally acknowledged that exercise programs which improve the fitness of the heart and lungs, correct poor posture, build muscular strength, increase joint flexibility and improve balance are beneficial to people of all ages and can reduce the pain and stiffness associated with arthritis. The ancient Chinese martial art of Tai Chi, in an appropriately modified style, is a form of exercise which achieves all this and also enhances both mental and physical relaxation.

Paragraph 10: Dr Paul Lam, a family physician who lives in Sydney Australia began to have signs of arthritis after graduating from medical school. He took up Tai Chi and found it improved his arthritis and enabled him to enjoy his chosen and busy lifestyle. He is now a highly respected Tai Chi teacher and practitioner and has created a number of Tai Chi programs to improve people’s health and well-being. Arthritis Foundations and organisations in the Britain, America and Australia, New Zealand support his work. He has travelled the world to train instructors in the Tai Chi for Arthritis Program and produced books, videos and DVDs.

Paragraph 11: The Sun style Tai Chi movements are fluid, gentle and slow and help reduce the pain and stiffness associated with arthritic conditions. The movements incorporate breathing techniques and place an emphasis on posture and on the importance of weight transference which is an essential component of good balance. To ensure smoothness and harmony they require a mental as well as a physical commitment. People who practice these movements regularly, either individually in their homes or with a group in a park or community hall, report many benefits.

Paragraph 12: In many countries there are government funded and other support organizations whose purpose is not only to fund raise for further medical research into a cure for arthritis but also equally to provide comprehensive advice and assistance for people living with arthritis; This can include running education programs and seminars to provide the public with reliable and well researched information and also to providing aids to help in everyday living. These aids range from simple devices to assist in opening jars and cans and to larger equipment to assist with mobility.

Paragraph 13: Ultimately, to live as full a life as possible with an arthritic condition, you need to gain a full understanding of your condition. This can be achieved by working with a medical care team who shares their knowledge, is supportive and recognizes the contributions you can make. The best outcomes require a close partnership between you, your doctor and any health professionals or practitioners involved in your treatment

Paragraph 14: A degree of self-management has proved effective in managing arthritic conditions. This can be achieved in a number of ways. Keep up to date and enquire about the latest research results. Learn about and choose foods that – will ensure you have a healthy well-balanced diet. Always take medicines as directed and do not try any new “natural” supplement or medication without first consulting with your doctor or pharmacist. Undertake an exercise regime such as Tai Chi that is suitable to you and that you can enjoy in the company of others.

Paragraph 15: Until such time as a cure for all forms of arthritis becomes a reality, a holistic approach to the control of arthritis incorporating many of the treatments, therapies and concepts outlined in this article, will help you discover that living with arthritis does not mean you cannot have an enjoyable and fulfilling life.

Q1. Which of the following statements is correct?
a. More adults in Australia have arthritis than in the US
b. More adults in the· US have arthritis than in Australia
c. Over 20 % of Australians have arthritis
d. 4 in every hundred people have arthritis
Q2. According to the article a cure for arthritis is:
a. Much too expensive to justify b. A major focus for Australian scientists
c. Hard to find d. Likely within 2 – 3 years
Q3. Which of the following statements is not reflected in the article?
a. Paracetamol has few side-effects
b. Some powerful drugs can provide a permanent cure
c. Pregnancy and lactation contraindicate the use of certain drugs
d. Powerful non-steroidal anti- inflammatory drugs can provide effective relief from pain, joint stiffness and inflammation.
Q4. Which of the following statements is correct?
a. In the US hip replacement surgery has increased by 94.1% in the last decade
b. Such surgery is unsuitable for the elderly
c. Hip replacement surgery usually improves mobility
d. Hip replacement surgery is not expensive and is easily accessible
Q5. According to the article which one of the following statements is false?
a. Glucosamine dietary supplement is clinically proven
b. Natural products can have side effects
c. A number of nutritional supplements may relieve the inflammation, pain and slow degeneration of effected joints.
d. Omega-3 fatty acids can help reduce inflammation
Q6. In paragraph 8 the expression anecdotal evidence can best be described as:
a. A personal observation b. Scientific investigation c. An old wife’s tale d. None of the above
Q7. Which of the following statements appear in the article relating to diet?
a. Alcohol in moderc,1tion is beneficial
b. Carbonated drinks are recommended
c. Arthritis sufferers indicate that some foods adversely affect their condition
d. Fatty fish such as herring, tuna, mackerel and sword fish must be eaten twice weekly
Q8. In which paragraph can you find a description a style of Tai Chi which is useful for sufferers of arthritis?
a. Paragraph 9 b. Paragraph 10 c. Paragraph 11 d. Paragraph 12

PART C. TEXT 2. Choose the answer (A, B, C or D)
INFECTIOUS DISEASES AND CLIMATIC INFLUENCES

Paragraph 1: Complex dynamic relationships between humans, pathogens, and the environment lead to the emergence of new diseases and the re-emergence of old ones. Due to concern about the impact of increasing global climate variability and change, many recent studies have focused on relationships between infectious disease and climate.

Paragraph 2: Climate can be an important determinant of vector-borne disease epidemics: geographic and seasonal patterns of infectious disease incidence are often, though not always, driven by climate factors. Mosquito- borne diseases, such as malaria, dengue f ever, and Ross River virus, typically show strong seasonal and geographic patterns, as do some intestine diseases. These patterns are unsurprising, given the influence of climate on pathogen replication, vector and disease., reservoir populations, and human societies. In Sweden, a trend toward milder winters and early spring arrival may be implicated in an increased incidence of tick-borne encephalitis. The recent resurgence of malaria in the East African highlands may be explained by increasing temperatures in that region. However, yet there are relatively few studies showing clear climatic influences on infectious diseases at inter-annual or longer timescales.

Paragraph 3: The semi-regular El Nifio climate cycle, centred on the Pacific Ocean, has an important influence on inter-annual climate patterns in many parts of the world. This makes El Nifio an attractive, albeit imperfect, analogue for the effects of global climate change. In Peru, daily admissions for diarrhoea increased by more than 2-f old during an El Nifio event, compared with expected trends based on the previous five years. There is evidence of a relationship between El Nifio and the timing of cholera epidemics in Peru and Bangladesh; of ciguatera in the Pacific islands; of Ross River virus epidemics in Australia; and of dengue and malaria epidemics in several countries. The onset of meningococcal meningitis in Mali is associated with large-scale atmospheric circulation.

Paragraph 4: These studies were performed mostly at country scale, reflecting the availability of data sources and, perhaps, the geographically local effects of El Nifio on climate. In part because of this geographic “patchiness” of the epidemiological evidence, the identification of climatic factors in infectious disease dynamics, and the relative importance of the different factors, remains controversial. For example, it has been suggested that climate trends are unlikely to contribute to the timing of dengue epidemics in Thailand. However, recent work has shown a strong but transient association between dengue incidence and El Nifio in Thailand. This association may possibly be caused by a “pacemaker-like” effect in which intrinsic disease dynamics interact with climate variations driven by El Nifio to propagate travelling waves of infection.

Paragraph 5: A new study on cutaneous leishmaniasis by Chaves and Pascual also provides fresh evidence of a relationship between climate and vector-borne disease. Chaves and Pascual use a range of mathematical tools to illustrate a clear relationship between climatic variables and the dynamics of cutaneous leishmaniasis, a skin infection transmitted by sandflies. In Costa Rica, cutaneous leishmaniasis displays three-year cycles that coincide with those of El Nifio. Chaves and Pascual use this newly demonstrated association to enhance the forecasting ability of their models and to predict the epidemics of leishmaniasis up to one year ahead. Interestingly, El Nifio was a better predictor of disease than temperature, possibly because this large-scale index integrates numerous environmental processes and so is a more biologically relevant measure than local temperature. As the authors note, the link between El Nifio and epidemics of leishmaniasis might be explained by large-scale climate effects on population susceptibility. Susceptibility, in turn, may be related to lack of specific immunity or poor nutritional status, both of which are plausibly influenced by climate.

Paragraph 6: Chaves and Pascual have identified a robust relationship between climate and disease, with changes over time in average incidence and in cyclic components. The dynamics of cutaneous leishmaniasis evolve coherently with climatic variables including temperature and El Nifio indices, demonstrating a strong association between these variables, particularly after 1996. Long¬ term changes in climate, human demography, and social features of human populations have large effects on the dynamics of epidemics as underlined by the analyses of some large datasets on whooping cough and measles. Another illuminating example is the transient relationship between cholera prevalence and El Nifio oscillations. In Bangladesh, early in the 20th century, cholera and El Nifio appeared unrelated, yet a strong association emerged in 1980- 2001. Transient relationships between climate and infectious disease may be caused by interactions between climate and intrinsic disease mechanisms such as temporary immunity. If population susceptibility is low, even large increases in transmission potential due to climate farcing will not result in a large epidemic.

Paragraph 7: A deeper understanding of infectious disease dynamics is important in order to forecast, and perhaps forestall, the effects of dramatic global social and environmental changes. Conventional statistical methods may f ail to reveal a relationship between climate and health when discontinuous associations are present. Because classical methods quantify average associations over the entire dataset, they may not be adequate to decipher long-term but discontinuous relationships between environmental exposures and human health. On the other hand, relationships between climate and disease could signal problems for disease prediction. Unless all important effects are accounted for, dynamic forecast models may prove to have a limited shelf life.

Q1. According to paragraph 2, which of the following is true?
a. The incidence of infectious diseases is rarely caused by climatic factors.
b. Seasonal variations and geography always lead to increases in mosquito borne diseases.
c. An increase in the rate of tick-borne encephalitis has been caused by milder winters and early arrival spring in Sweden.
d. Malaria may have reappeared in East African highlands due to higher temperatures.
Q2. Which of the following would be the most appropriate heading for the paragraph 2?
a. The link between global warming and disease epidemics.
b. The strong relationship between climate and outbreaks of disease.
c. The unexpected influence of climate on infectious diseases.
d. The need for further research into climate change and infectious diseases.
Q3. Which of the following is closest in meaning to the expression relatively few?
a. comparatively few
b. b. several
c. c. quite a few
d. d. three
Q4. In paragraph 3, which of the fallowing is not true?
a. In Peru, the El Nino event led to increased rates of diarrhoea.
b. El-Nino has a significant yearly effect on global climate patterns.
c. Outbreaks of cholera in Bangladesh and Peru can be linked to El Nino.
d. Meningococcal meningitis in Mali is influenced by weather patterns.
Q5. The main point the author wishes to raise in paragraph 4 is?
a. Despite differing opinions, there is strong current evidence linking climate factors and infectious disease.
b. There is insufficient data to determine how significant climatic f actors are on infectious disease.
c. The link between climate trends and disease epidemics is still inconclusive.
d. There is no connection between climatic trends and dengue fever in Thailand.
Q6. According to paragraph 5 which of the following statements is correct?
a. Outbreaks of cutaneous leishmaniasis in Costa Rica correspond with El Nino events.
b. The mathematical tools used by Chaves and Pascual demonstrate the link between sandflies and cutaneous leishmaniasis.
c. Research by Chaves and Pascual will allow for annual prediction of leishmaniasis outbreaks.
d. El Nino is an accurate predictor disease due its complexity and biological relevance.

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Show answer
THE GLOBAL BURDEN OF DEMENTIA

Part A:

1. B

2. C

3. D

4. C

5. B

6. A

7. C

8. Alzheimer’s Disease

9. INTERHEART

10. 24-2 million

11. Sub-Saharan Africa

12. China and India

13. Europe

14. FOA – approval

15. Latin America

16. Agitation

17. Life expectancy

18. Cholinesterase inhibitor

19. Aggressive

20. Demographic agency

Part B:

1. D B

2. D C

3. A

4. B

5. C

6. B

Part C:

1. A

2. C

3. B

4. C

5. A

6. A

7. D

8. C

9. D

10. B

11. A

12. B

13. A

14. C