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An editorial is presented on the public health priority of reducing nuclear war risks, and it highlights the inadequacy of current arms control efforts and the catastrophic consequences of nuclear weapon use. It reports that Health professionals, led by organizations like the International Physicians for the Prevention of Nuclear War (IPPNW), have played a crucial role in advocating for nuclear disarmament and call for continued efforts from the health community.

Background: Impaired recovery of blood pressure (BP) after standing has been shown to be related to cognitive function and mortality in people without dementia, but its role in people with Alzheimer's disease (AD) is unknown. The aim of this study was to investigate the association of the orthostatic BP response with cognitive decline and mortality in AD. Methods: In this post hoc analysis of a randomized controlled trial (Nilvad), we measured the beat-to-beat response of BP upon active standing in mild-to-moderate AD. This included the initial drop (nadir within 40 seconds) and recovery after 1 minute, both expressed relative to resting values. We examined the relationship between a small or large initial drop (median split) and unimpaired (≥100%) or impaired recovery (<100%) with 1.5-year change in Alzheimer's Disease Assessment-cognitive subscale (ADAS-cog) scores and all-cause mortality. Results: We included 55 participants (age 73.1 ± 6.2 years). Impaired BP recovery was associated with higher increases in ADAS-cog scores (systolic: β [95% confidence interval] = 5.6 [0.4-10.8], p = .035; diastolic: 7.6 [2.3-13.0], p = .006). During a median follow-up time of 49 months, 20 participants died. Impaired BP recovery was associated with increased mortality (systolic: HR [95% confidence interval] = 2.9 [1.1-7.8], p = .039; diastolic: HR [95% confidence interval] = 5.5 [1.9-16.1], p = .002). The initial BP drop was not associated with any outcome. Results were adjusted for age, sex, and intervention group. Conclusions: Failure to fully recover BP after 1 minute of standing is associated with cognitive decline and mortality in AD. As such, BP recovery can be regarded as an easily obtained marker of progression rate of AD. [ABSTRACT FROM AUTHOR]

Background: Physical activity is linked to many positive health outcomes, stimulating the development of exercise programs. However, many falls occur while walking and so promoting activity might paradoxically increase fall rates, causing injuries, and worse quality of life. The relationship between activity exposure and fall rates remains unclear. We investigated the relationship between walking activity (exposure to risk) and fall rates before and after an exercise program (V-TIME).Methods: One hundred and nine older fallers, 38 fallers with mild cognitive impairment (MCI), and 128 fallers with Parkinson's disease (PD) were randomly assigned to one of two active interventions: treadmill training only or treadmill training combined with a virtual reality component. Participants were tested before and after the interventions. Free-living walking activity was characterized by volume, pattern, and variability of ambulatory bouts using an accelerometer positioned on the lower back for 1 week. To evaluate that relationship between fall risk and activity, a normalized index was determined expressing fall rates relative to activity exposure (FRA index), with higher scores indicating a higher risk of falls per steps taken.Results: At baseline, the FRA index was higher for fallers with PD compared to those with MCI and older fallers. Walking activity did not change after the intervention for the groups but the FRA index decreased significantly for all groups (p ≤ .035).Conclusions: This work showed that V-TIME interventions reduced falls risk without concurrent change in walking activity. We recommend using the FRA index in future fall prevention studies to better understand the nature of intervention programs. [ABSTRACT FROM AUTHOR]

Background: Hypertension and cognitive impairment often coexist in older people. Office blood pressure measurement is a poor indicator for diagnosing hypertension in the general population. However, its diagnostic accuracy has not been substantially studied in patients with cognitive impairment. Aim: The aim of this study was to determine the proportion of misdiagnosis of hypertension in patients with mild cognitive impairment and dementia compared to no cognitive impairment, by comparing office blood pressure measurement with home blood pressure measurement. Methods: A cross-sectional study including consecutive patients visiting a memory clinic between 2014 and 2017. Home blood pressure was measured for one week according to the European guidelines. Office blood pressure was assessed during routine clinical practice. Using guideline definitions for normal blood pressure and hypertension, we investigated the proportion of disagreement between office blood pressure measurement and home blood pressure measurement. Univariable and multivariable logistic regression compared disagreement in diagnosis between patients with dementia, mild cognitive impairment and no cognitive impairment. Results: Of 213 patients (aged 73.4±9.0 years, 42% women) 82 had dementia, 65 had mild cognitive impairment and 66 had no cognitive impairment. Mean office blood pressure was 156/84±23/11 mmHg and mean home blood pressure was 139/79±16/10 mmHg. In 31% of patients, there was disagreement in hypertension diagnosis. This proportion was higher for mild cognitive impairment (38.5%) and dementia (35.4%) compared to no cognitive impairment (18.2%), with adjusted odds ratios of 3.7 (95% confidence interval 1.5–9.0), P =0.005 for mild cognitive impairment and 3.4 (1.3–8.6), P =0.011 for dementia. Conclusions: In memory clinic patients with dementia and mild cognitive impairment, the diagnostic accuracy of office blood pressure measurement is lower compared to patients without cognitive impairment. To avoid the risk of making improper treatment decisions in this vulnerable group, a diagnosis of hypertension should be based on home blood pressure measurement, not office blood pressure measurement. [ABSTRACT FROM AUTHOR]

Background: Finding ways to quantify resilience as a predictor of a person's resistance to health challenges is important to improve healthy aging. This study investigated a unique sample of high-functioning older persons in whom traditional markers of frailty and functional decline are largely absent. Translating complex dynamical systems theory to humans, dynamical indicators of resilience in postural balance time series may sensitively discriminate levels of resilience.Methods: This study investigated 240 high-functioning older adults (mean age 83.9 ± 2.9 years, 59% male), of whom 94 hikers of the Nijmegen Four Days Marches. Participants stood upright on a force plate with eyes open and feet at shoulder width for 30 seconds. Center of pressure data were analyzed for dynamical indicators of resilience (variance and temporal autocorrelation). After 1 year, participants were compared on a modified Successful Aging Index.Results: Mediolateral center of pressure displacement of hikers exhibited significantly lower variance (2.2 vs 2.8 mm, p < .001) and temporal autocorrelation (0.59 vs 0.65, p = .006), compared with nonhikers. Multivariably adjusted, mediolateral variance was significantly associated with successful aging at baseline (b = -1.43, p = .003) and 1-year follow-up (b = -1.94, p < .001), while mediolateral temporal autocorrelation was not.Conclusions: Two dynamical indicators of resilience (variance and temporal autocorrelation) calculated on time series of mediolateral center of pressure displacement differed between hikers and nonhikers within a group of high-functioning older adults. In the whole group, variance was independently associated with successful aging at baseline and after 1 year. Our results support the hypothesis that resilience of older persons may be estimated from time series of natural fluctuations of bodily functions. [ABSTRACT FROM AUTHOR]

Background: As the number of patients with complex healthcare needs grows, inter-professional collaboration between primary care professionals must be constantly optimized. General practitioners (GPs) and community nurses (CNs) are key professions in primary care; however, poor GP-CN communication is common, and research into the factors influencing its quality is limited.Objective: To explore patient-related GP-CN communication and facilitating and hindering factors, and to identify strategies to enhance this communication.Method: A qualitative focus group design was used to identify the facilitating and hindering factors and strategies for improvement. In a Dutch primary care setting, 6 mono-professional focus group interviews (3 meetings of 13 GPs; 3 meetings of 18 CNs) were organized between June 2015 and April 2016, recorded and transcribed verbatim. Two independent researchers performed the coding of these interviews, identifying their categories and themes.Results: Results show that, despite the regular contact between GPs and CNs, communication was generally perceived as poor in effectiveness and efficiency by both professions. Mutual trust was considered the most important facilitating factor for effective communication. Profession-specific factors (e.g. differences in responsibility and profession-specific language) and organizational factors (e.g. lack of shared care plans, no in-person communication, lack of time) may be of influence on communication. Participants' suggestions for improvement included organizing well-structured and reimbursed team meetings and facilitating face-to-face contact.Conclusion: GP-CN patient-related communication benefits most from trusting inter-personal relationships. Inter-professional training programmes should address both professional and organizational factors and should be evaluated for their effect on quality of care. [ABSTRACT FROM AUTHOR]

Background: We currently still lack valid methods to dynamically measure resilience for stressors before the appearance of adverse health outcomes that hamper well-being. Quantifying an older adult's resilience in an early stage would aid complex decision-making in health care. Translating complex dynamical systems theory to humans, we hypothesized that three dynamical indicators of resilience (variance, temporal autocorrelation, and cross-correlation) in time series of self-rated physical, mental, and social health were associated with frailty levels in older adults.Methods: We monitored self-rated physical, mental, and social health during 100 days using daily visual analogue scale questions in 22 institutionalized older adults (mean age 84.0, SD: 5.9 years). Frailty was determined by the Survey of Health, Ageing and Retirement in Europe (SHARE) frailty index. The resilience indicators (variance, temporal autocorrelation, and cross-correlation) were calculated using multilevel models.Results: The self-rated health time series of frail elderly exhibited significantly elevated variance in the physical, mental, and social domain, as well as significantly stronger cross-correlations between all three domains, as compared to the nonfrail group (all P < 0.001). Temporal autocorrelation was not significantly associated with frailty.Conclusions: We found supporting evidence for two out of three hypothesized resilience indicators to be related to frailty levels in older adults. By mirroring the dynamical resilience indicators to a frailty index, we delivered a first empirical base to validate and quantify the construct of systemic resilience in older adults in a dynamic way. [ABSTRACT FROM AUTHOR]

Background: Prospective studies in the general population show that slow gait speed is associated with cognitive decline and clinical progression to dementia. However, longitudinal studies in memory clinic populations are mostly lacking. We aimed to study the association between gait speed and grip strength and cognitive functioning at baseline and cognitive decline over time in memory clinic patients with subjective cognitive decline and mild cognitive impairment.Methods: We included 309 patients (age 70 ± 9 years, 108 [35%] women, Mini-Mental State Examination 27 ± 3 points). Baseline gait speed was assessed over 15 feet, grip strength with a hydraulic hand dynamometer. Cognitive functioning was assessed annually with a comprehensive test battery during 3 years.Results: Age- and gender-adjusted linear mixed models showed that slower gait speed was related to worse baseline attention, memory, information processing speed, and verbal fluency. Longitudinally, gait speed was related to decline in information processing speed and executive functioning. Weaker grip strength was related to worse baseline information processing speed and executive functioning but there were no longitudinal associations. Cox proportional hazards models revealed no significant associations with clinical progression.Conclusions: Our findings suggest that markers of physical performance are related to current cognitive status and modestly related to cognitive decline but are seemingly not useful as an early marker of incident clinical progression. [ABSTRACT FROM AUTHOR]

Background: falling is a major health problem.Objective: to investigate the predictive value for falls of the maximum step length and gait speed.Design: a prospective cohort study.Setting: geriatric outpatient clinic.Subjects: three hundred and fifty-two community-dwelling older persons screened by their general practitioner.Methods: maximum step length and gait speed were recorded as part of a comprehensive geriatric assessment. One-year follow-up was performed using the fall telephone system.Results: one hundred and thirty-six (39%) of all subjects (mean age: 76.2 years, standard deviation: 4.3, 55% female), fell at least once, of whom 96 were injured. Predictive values for any falls of both maximum step length and gait speed were low (area under the curve (AUC): 0.53 and 0.50) and slightly better for recurrent falls (maximum step length AUC: 0.64 and gait speed AUC: 0.59). After adding age, gender and fall history to the prediction model, the AUC was 0.63 for maximum step length and 0.64 for gait speed, and for recurrent falls, the AUC was 0.69 both for maximum step length and gait speed. The prediction of fall-related injuries showed similar results. A higher maximum step length score indicated a lower likelihood for falls (hazards ratio 0.36; 95% confidence interval 0.17–0.78).Conclusions: maximum step length and gait speed as single-item tools do not have sufficient power to predict future falls in community-dwelling older persons. [ABSTRACT FROM AUTHOR]

Background: patients suspected of dementia frequently undergo additional diagnostic testing (e.g. brain imaging or neuropsychological assessment) after standard clinical assessment at a memory clinic. This study investigates the use of additional testing in an academic outpatient memory clinic and how it influences the initial diagnosis.Methods: the initial diagnosis after standard clinical assessment (history, laboratory tests, cognitive screening and physical and neurological examination) and the final diagnosis after additional testing of 752 memory clinic patients were collected. We specifically registered if, and what type of, additional testing was requested.Results: additional testing was performed in 518 patients (69%), 67% of whom underwent magnetic resonance imaging, 45% had neuropsychological assessment, 14% had cerebrospinal fluid analysis and 49% had (combinations of) other tests. This led to a modification of the initial diagnosis in 17% of the patients. The frequency of change was highest in patients with an initial non-Alzheimer's disease (AD) dementia diagnosis (54%, compared with 11 and 14% in patients with AD and ‘no dementia’; P < 0.01). Finally, after additional testing 44% was diagnosed with AD, 9% with non-AD dementia and 47% with ‘no dementia’.Conclusion: additional testing should especially be considered in non-AD patients. In the large group of patients with an initial AD or ‘no dementia’ diagnosis, additional tests have little diagnostic impact and may perhaps be used with more restraint. [ABSTRACT FROM AUTHOR]

Background. Normally, standing up causes a blood pressure (BP) drop within 15 seconds, followed by recovery to baseline driven by BP control mechanisms. The prognostic value of this initial BP drop, but also of the recovery hereafter, is unknown. The aim of this study was to examine the prognostic value of these BP characteristics in response to standing. Methods. In a retrospective cohort study of 238 consecutive patients visiting our falls outpatient clinic, we examined the relation between all-cause mortality and BP decline and recovery directly after active standing up with Cox proportional hazards analyses. Results. Of 238 patients (mean age 78.4 ± 7.8 years), during a median follow-up of 21.0 months, 36 (15%) patients died. Neither absolute nor relative (%) initial BP drop after standing predicted mortality. In contrast, the magnitude of BP recovery 40–60 seconds after standing was associated with mortality, even after adjustment for age, comorbidity, and other baseline characteristics. When systolic BP had recovered to less than 80% of prestanding baseline after 60 seconds of standing, this was a powerful independent predictor of mortality (hazard ratio: 3.00; 95% confidence interval 1.17–7.68). Conclusions. Failure to recover from BP decline in the first minute after active standing up is associated with excess mortality in falls clinic patients. A recovery of systolic BP to less than 80% of baseline after 60 seconds may be used as an easily available cardiovascular marker for increased mortality risk in older falls clinic patients. [ABSTRACT FROM PUBLISHER]

BACKGROUND: Though highly prevalent, the pathophysiology of orthostatic hypotension (OH), postprandial hypotension (PPH), and carotid sinus hypersensitivity (CSH) are rarely studied together. Therefore, we conducted such a comprehensive study focusing on the common role of the cardiovascular autonomic system. We hypothesized that in geriatric patients, OH, PPH, and CSH are manifestations of cardiovascular autonomic dysfunction and investigated state-of-the-art cardiovascular autonomic function indices in a group of geriatric falls or syncope patients. METHODS: In a cross-sectional study of 203 consecutive eligible falls clinic patients, we compared heart rate variability (HRV), blood pressure variability (BPV), and baroreflex sensitivity (BRS) as potential autonomic function determinants of the three different hypotensive syndromes. RESULTS: OH, PPH, and CSH were diagnosed in 53%, 57%, and 50% of the patients, respectively. In a population relevant for geriatric practice, we found no differences in HRV, BPV, and BRS between patients with and without OH, with and without PPH, and with and without CSH, respectively, nor between patients with and without falls, dizziness, or syncope as presenting symptom, respectively. CONCLUSIONS: In geriatric patients with hypotensive syndromes, cardiovascular autonomic function as measured by HRV, BPV, and BRS is comparable to patients without such syndromes. These findings argue against a single or dominant etiological factor, that is, cardiac autonomic dysfunction and underline the structured, broad, and multifactorial approach to elderly patients with falls and/or syncope as proposed in the current evidence-based syncope guidelines. [ABSTRACT FROM AUTHOR]

Background Patient involvement in clinical decision making is increasingly advocated. Although older patients may be more reluctant to become involved, most do appreciate being informed. However, knowledge about their experiences with and preferences for receiving information is limited, and even less is known about these topics for frail older people. Objective To explore the experiences of frail older people and informal caregivers with receiving information from health care professionals as well as their preferences for receiving information. Methods We conducted semi-structured interviews with frail older people (n = 11, 65–90 years) and informal caregivers (n = 11, 55–87 years). Interviews were transcribed verbatim and analysed using a grounded theory approach. Results Frail older people and informal caregivers varied in their information needs and discussed both positive and negative experiences with receiving information. They preferred receiving verbal information from their physician during the consultation; yet would appreciate receiving brief, clearly written information leaflets in addition. They employed several strategies to enhance the information provided, i.e. advocacy, preparing for a consultation and searching their own information. Contextual factors for receiving information, such as having enough time and having a good relationship with professionals involved, were considered of great importance. Conclusions Participants described a wide range of experiences with and preferences for receiving information. However, even if the information provided would meet all their preferences, this would be of limited significance if not provided within the context of an ongoing trusting relationship with a professional, such as a GP or practice nurse, who genuinely cared for them. [ABSTRACT FROM PUBLISHER]

Background: fear of falling (FoF) has great impact on functioning and quality of life of older people, but its effects on gait and balance are largely unknown. Methods: we examined FoF in 100 participants aged ~75 years, using the Activities-specific Balance Confidence scale. Participants with a mean score <67% were assigned to the FoF group. We quantified gait and balance during walking at the preferred velocity with and without a cognitive dual task (arithmetic task and verbal fluency), using an electronic walkway (Gaitrite®) and a trunk accelerometer (SwayStar®), Primary outcome measures were gait velocity, stride-length and stride-time variability, as well as mediolateral angular displacement and velocity. Results: gait velocity was significantly lower (P < 0.05) and stride-length and stride-time variability were significantly higher (P < 0.05) in the FoF group. However, after standardisation for gait velocity, differences became non-significant. Mediolateral angular displacement and velocity were not associated with FoF. We found no difference between the FoF and no-FoF group with respect to the dual-task effect on gait and balance variables. Conclusions: the lower gait velocity in the FoF group may be a useful adaptation to optimise balance, rather than a sign of decreased balance control. The ability to attend to a secondary task during walking is not influenced by FoF. [ABSTRACT FROM AUTHOR]

Background. There is growing interest in geriatric care for community-dwelling older people. There are, however, relatively few reports on the economics of this type of care. This article reports about the cost-effectiveness of the Dutch Geriatric Intervention Program (DGIP) compared to usual care in frail older people at 6-month follow-up from a health care system's point of view. Methods. We conducted this economic evaluation in an observer-blind randomized controlled trial (Dutch EASYcare Study: ClinicalTrials.gov Identifier NCT00105378). Difference in treatment effect was calculated as the difference in proportions of successfully treated patients (prevented functional decline accompanied by improved well-being). Incremental treatment costs were calculated as the difference in mean total care costs. The incremental cost-effectiveness ratio (ICER) was expressed as total cost per successful treatment. Bootstrap methods were used to determine confidence intervals (CI) for these measures. Results. The average cost of the intervention under study (DGIP) was 998 euros (95% CI, 888-1108). The increment in total cost resulting from DGIP was a little over 761 euros (-3336 to 4687). Hospitalization and institutionalization costs were less; home care, adult day care, and meals-on-wheels costs were higher. There was a significant difference in proportions of successful treatments of 22.3% (4.3-41.4). The number needed to treat was approximately 4.7 (2.3-18.0). The ICER is 3418 euros per successful treatment (-21,458 to 45,362). The new treatment is cost-effective at a willingness-to-pay of 34,000 euros. Conclusion. The results of this economic evaluation suggest that DGIP is an effective addition to primary care for frail older people at a reasonable cost. [ABSTRACT FROM AUTHOR]

Background. The effectiveness of community-based geriatric intervention models for vulnerable older adults is controversial. We evaluated a problem-based multidisciplinary intervention targeting vulnerable older adults at home that promised efficacy through better timing and increased commitment of patients and primary care physicians. This study compared the effects of this new model to usual care. Methods. Primary care physicians referred older people for problems with cognition, nutrition, behavior, mood, or mobility. One hundred fifty-one participants (mean age 82.2 years, 74.8% women) were included in a pseudocluster randomized trial with 6-month follow-up for the primary outcomes. Eighty-five participants received the new intervention, and 66 usual care. In the intervention arm, geriatric nurses visited patients at home for geriatric assessment and management in cooperation with primary care physicians and geriatricians. Modified intention-to-treat analyses focused on differences between treatment arms in functional abilities (Groningen Activity Restriction Scale-3) and mental well-being (subscale mental health Medical Outcomes Study [MOS]-20), using a mixed linear model. Results. After 3 months, treatment arms showed significant differences in favor of the new intervention. Functional abilities improved 2.2 points (95% confidence interval [CI], 0.34.2) and well-being 5.8 points (95% CI, 0.1-11.4). After 6 months, the favorable effect increased for well-being (9.1; 95% CI, 2.4-15.9), but the effect on functional abilities was no longer significant (1.6; 95% CI, -0.7 to 3.9). Conclusions. This problem-based geriatric intervention improved functional abilities and mental well-being of vulnerable older people. Problem-based interventions can increase the effectiveness of primary care for this population. [ABSTRACT FROM AUTHOR]

Editorial. Deals with malnutrition research. Categories of malnutrition; Reason for considering malnutrition as a geriatric syndrome; Syndromes related to malnutrition.

Presents a response by Marcel G. M. Olde Rikkert and Anne-Sophie Rigaud to a letter to the editor about their article "Malnutrition Research: High Time to Change the Menu," in the 2003 issue of the "Age and Ageing."