Search

Background: Multiple factors influence the recovery process of low back pain (LBP). The identification and increased knowledge of prognostic factors might contribute to a better understanding of the course of LBP. The purpose of this study is to investigate the association of the STarT Back Screening Tool (SBST) risk score and the type of leg pain (non-radiating LBP, referred non-radicular, and radicular radiating leg pain) with the disability trajectory (at baseline, the slope, and recovery at one year) in adults with low back pain. Methods: This is a prospective cohort study in 347 patients with low back pain who sought physiotherapy care at three primary care practices in the Netherlands. Linear mixed models were estimated to describe the association of the SBST risk score and the type of leg pain with disability at baseline, the slope in the disability trajectory, and at twelve months follow-up. Results: A medium/high risk score on the SBST is associated with higher baseline disability scores on the Oswestry Disability Index (ODI), faster initial recovery, and still a higher disability ODI score at 12 months follow-up. Non-radicular referred and radicular radiating leg pain were associated with worse baseline disability ODI scores in LBP. This association was not present for the initial recovery or at the 12 months follow-up. Conclusion: The SBST is associated with the LBP recovery trajectory. The SBST might be a useful tool to predict the disability trajectory in a heterogeneous group of people with low back pain in primary care and might, therefore, be recommended in future clinical practice guidelines. The type of leg pain was not associated with the recovery trajectory of LBP. Future research might focus on evaluating different types of leg pain. Trial registration: Clinicaltrials.gov: 109,643. [ABSTRACT FROM AUTHOR]

Background: High day-to-day blood pressure variability (BPV) has been associated with an increased risk for cognitive decline and mortality in the general population. Whether BPV is associated with increased all-cause mortality in older people with cognitive impairment is unknown.Objective: To investigate the association between day-to-day home BPV and all-cause mortality in older patients attending a memory clinic.Methods: We included 279 patients attending a memory clinic, who measured home blood pressure (BP) for 7 consecutive days in the morning and evening. Within-subject BPV was defined as the variation independent of the mean (VIM). Time-to-death was verified through the Dutch population registry. Cox proportional hazard regression was used. Separate analyses were performed for morning-to-morning and evening-to-evening BPV.Results: Mean age was 73±9 years, dementia and mild cognitive impairment were diagnosed in 35% and 34% respectively, and mean home BP was 139/79 mmHg. After a mean follow-up of 3.2 years, 52 patients had died. Neither day-to-day systolic nor diastolic VIM were associated with mortality (adjusted hazard ratio [HR] systolic VIM: 0.99, 95% -CI 0.92-1.06, p = 0.770, HR diastolic VIM: 1.04, 95% -CI 0.93-1.17, p = 0.517). When morning and evening measurements were analyzed separately, systolic morning-to-morning VIM was associated with mortality (adjusted HR: 1.09, 95% -CI 1.01-1.18, p = 0.033).Conclusion: In this study, day-to-day BPV was not associated with all-cause mortality in patients attending a memory clinic. However, morning-to-morning BPV was. Due to the short assessment window, there is still a lack of clarity; hence future research is warranted to clarify the role of all BPV components in aging. [ABSTRACT FROM AUTHOR]

Clinical reasoning and research in modern geriatrics often prioritises the disease concept. This is understandable as it has brought impressive advances in medicine (e.g. antibiotics, vaccines, successful cancer treatment and many effective surgeries). However, so far the disease framework has not succeeded in getting us to root causes of many age-related chronic diseases (e.g. Alzheimer's disease, diabetes, osteoarthritis). Moreover, in aging and disease constructs alone fail to explain the variability in illness presentations. Therefore, we propose to apply the underused illness concept in a new way by reconsidering the importance of common symptoms in the form of a dynamic network of symptoms as a complementary framework. We show that concepts and methods of complex system thinking now enable to fruitfully monitor and analyse the multiple interactions between symptoms in such in networks, offering new routes for prognosis and treatment. Moreover, close attention to the symptoms that bother older persons may also improve weighing the therapeutic objectives of well-being and survival and aligning treatment targets with the patients' priorities. [ABSTRACT FROM AUTHOR]

Background: Preoperative colorectal cancer care pathways for older patients show considerable practice variation between Dutch hospitals due to differences in interpretation and implementation of guideline-based recommendations. This study aims to report this practice variation in preoperative care between Dutch hospitals in terms of technical efficiency and identifying associated factors. Methods: Data on preoperative involvement of geriatricians, physical therapists and dieticians and the clinicians' judgement on prehabilitation implementation were collected using quality indicators and questionnaires among colorectal cancer surgeons and specialized nurses. These data were combined with registry-based data on postoperative outcomes obtained from the Dutch Surgical Colorectal Audit for patients aged ≥75 years. A two-stage data envelopment analysis (DEA) approach was used to calculate bias-corrected DEA technical efficiency scores, reflecting the extent to which a hospital invests in multidisciplinary preoperative care (input) in relation to postoperative outcomes (output). In the second stage, hospital care characteristics were used in a bootstrap truncated regression to explain variations in measured efficiency scores. Results: Data of 25 Dutch hospitals were analyzed. There was relevant practice variation in bias-corrected technical efficiency scores (ranging from 0.416 to 0.968) regarding preoperative colorectal cancer surgery. The average efficiency score of hospitals was significantly different from the efficient frontier (p = <0.001). After case-mix correction, higher technical efficiency was associated with larger practice size (p = <0.001), surgery performed in a general hospital versus a university hospital (p = <0.001) and implementation of prehabilitation (p = <0.001). Conclusion: This study showed considerable variation in technical efficiency of preoperative colorectal cancer care for older patients as provided by Dutch hospitals. In addition to higher technical efficiency in high-volume hospitals and general hospitals, offering a care pathway that includes prehabilitation was positively related to technical efficiency of hospitals offering colorectal cancer care. [ABSTRACT FROM AUTHOR]

Background: Sedentary behaviour might be a potential risk factor for cognitive decline. However, the short-term effects of sedentary behaviour on (cerebro) vascular and cognitive performance in older people are unknown. Methods: We used a cross-over design with 22 older adults (78 years, 9 females) to assess the short-term hemodynamic and cognitive effects of three hours uninterrupted sitting and explored if these effects can be counteracted with regular (every 30 min) two-minute walking breaks. In addition, we investigated if low versus high mental activity during the three hours of sitting modified these effects. Before and after each condition, alertness, executive functioning, and working memory were assessed with the Test of Attentional Performance battery. Additionally, cerebral blood flow velocity (Transcranial Doppler) and blood pressure (Finapres) were measured in rest, and during sit-to-stand and CO2 challenges to assess baroreflex sensitivity, cerebral autoregulation, and cerebral vasomotor reactivity. Results: No short-term differences were observed in cognitive performance, cerebral blood flow velocity, baroreflex sensitivity, cerebral autoregulation, or cerebral vasomotor reactivity across time, or between conditions. Blood pressure and cerebrovascular resistance increased over time (8.6 mmHg (5.0;12.1), p < 0.001), and 0.23 in resistance (0.01;0.45), p = 0.04). However, these effects were not mitigated by mental activity or by short walking breaks to interrupt sitting. Conclusions: In older individuals, three hours of sitting did not influence cognitive performance or cerebral perfusion. However, the sitting period increased blood pressure and cerebrovascular resistance, which are known to negatively impact brain health in the long-term. Importantly, we found that these effects in older individuals cannot be mitigated by higher mental activity and/or regular walking breaks. Trial registration: Clinical trial registration URL: https://www.toetsingonline.nl/. Unique identifier: NL64309.091.17. Date of registration: 06–02–2018. [ABSTRACT FROM AUTHOR]

Objectives To determine the effect of chronic disorders and their co-occurrence on survival and functioning in community-dwelling older adults. Design Population-based cohort study. Setting Kungsholmen, Stockholm, Sweden. Participants Individuals aged 78 and older examined by physicians four times over 11 years (N = 1,099). Measurements Chronic diseases (grouped according to 10 organ systems according to the International Classification of Diseases, Tenth Revision, code) and multimorbidity (≥2 coexisting chronic diseases) were evaluated in terms of mortality, population attributable risk of death, median years of life lost, and median survival time with and without disability (need of assistance in ≥1 activities of daily living). Results Approximately one in four deaths were attributable to cardiovascular and one in six to neuropsychiatric diseases. Malignancy was the condition with the shortest survival time (2.5 years). Malignancies and cardiovascular disorders each accounted for approximately 5 years of life lost. In contrast, neurosensorial and neuropsychiatric conditions had the longest median survival time (>6 years), and affected people were disabled for more than half of this time. The most-prevalent and -burdensome condition was multimorbidity, affecting 70.4% of the population, accounting for 69.3% of total deaths, and causing 7.5 years of life lost. Finally, people with multimorbidity lived 81% of their remaining years of life with disability (median 5.2 years). Conclusion Survival in older adults differs in length and quality depending on specific conditions. The greatest negative effect at the individual (shorter life, greater dependence) and societal (number of attributable deaths, years spent with disability) level was from multimorbidity, which has made multimorbidity a clinical and public health priority. [ABSTRACT FROM AUTHOR]

Background: Informal care is essential for many people with dementia (PwD), but it often results in a considerable burden for the caregiver. The perseverance time instrument integrates the aspect of perceived burden with the caregiver's capacity to cope with the burden, in contrast to most available instruments, which measure solely the burden of caregiving. The aim of this study was to extend insight into psychometric properties of the perseverance time instrument, specifically the construct validity, responsiveness, and predictive validity, within the population of informal caregivers for PwD. Methods: Data from two studies among informal caregivers of community-dwelling PwD in the Netherlands were used. The first study included 198 caregivers from a single region in the Netherlands and lasted 1 year. The second was a cross-sectional nationwide study with 166 caregivers for PwD. Questionnaires of both studies included questions regarding demographics and informal care, perseverance time, and other informal caregiver outcomes (Caregiver Strain Index, Self-rated Burden scale, Care-related Quality of Life instrument, and visual analogue scale health scores). Construct validity and responsiveness were assessed using a hypothesis-testing approach. The predictive validity of demographic characteristics and perseverance time for living situation after 1 year (living at home, institutionalized, or deceased) was assessed with multivariable multinomial regression. Results: All but one of the hypotheses regarding construct validity were met. Three of five hypotheses regarding responsiveness were met. Perseverance time scores at baseline were associated with living situation after 1 year (p < 0.01), unlike age, sex, and relationship with PwD. Perseverance time strongly increased predictive power for living situation after 1 year (c-index between 0.671 and 0.775) in addition to demographic characteristics. Conclusions: This study supports previous findings regarding the construct validity of the perseverance time instrument and adds new evidence of good construct validity, responsiveness, and predictive validity. The predictive power of perseverance time scores for living situation exceeds the predictive power of other burden measures and indicates informal care as an important factor for maintaining the patient at home. [ABSTRACT FROM AUTHOR]

Background: Count scores, disease clustering, and pairwise associations between diseases remain ubiquitous in multimorbidity research despite two major shortcomings: they yield no insight into plausible mechanisms underlying multimorbidity, and they ignore higher-order interactions such as effect modification. Objectives: We argue that two components are currently missing but vital to develop novel multimorbidity metrics. Firstly, networks should be constructed which consists simultaneously of signs, symptoms, and diseases, since only then could they yield insight into plausible shared biological mechanisms underlying diseases. Secondly, learning pairwise associations is insufficient to fully characterize the correlations in a system. That is, synergistic (e.g., cooperative or antagonistic) effects are widespread in complex systems, where two or more elements combined give a larger or smaller effect than the sum of their individual effects. It can even occur that pairs of symptoms have no pairwise associations whatsoever, but in combination have a significant association. Therefore, higherorder interactions should be included in networks used to study multimorbidity, resulting in so-called hypergraphs. Methods: We illustrate our argument using a synthetic Bayesian Network model of symptoms, signs and diseases, composed of pairwise and higher-order interactions. We simulate network interventions on both individual and population levels and compare the ground-truth outcomes with the predictions from pairwise associations. Conclusion: We find that, when judged purely from the pairwise associations, interventions can have unexpected "side-effects" or the most opportune intervention could be missed. The hypergraph uncovers links missed in pairwise networks, giving a more complete overview of sign and disease associations. [ABSTRACT FROM AUTHOR]

Insight into older adults' physical resilience is needed to predict functional recovery after hospitalization. We assessed functional trajectories in response to acute illness and subsequent hospitalization and investigated baseline variables and dynamic variables associated with these trajectories. Prospective observational cohort study (Hospitalization-Associated Disability and impact on daily Life Study). This study included 207 older adults (aged 79.8 ± 6.9 years, 49% female, 57% frail) acutely hospitalized in 6 Dutch hospitals. Functional disability was assessed using the 15-item modified activities of daily living index retrospectively 2 weeks before admission, and prospectively from admission up to 3 months after discharge. Baseline variables including frailty, somatic, physical, and psychosocial factors were assessed at admission. Dynamic variables (step count, pain, fatigue, and fear of falling) were continuously or repeatedly assessed during hospitalization. We performed individual spline modeling using random effects. Baseline variables and within-person mean levels and variability in the dynamic variables were assessed as predictors of functional trajectories. Functional disability significantly increased before admission and decreased from admission to 3 months post discharge. Frail participants had a significantly higher increase in functional disability before admission compared with nonfrail participants. Lower step count, higher pain scores, and higher within-person variability in fear of falling were significantly associated with higher increase in functional disability before admission. Higher within-person variability in fear of falling was associated with more recovery. Older adults increase in functional disability before hospitalization and start to recover from admission onward. Frailty and dynamic variables are associated with a higher increase in functional disability after acute illness. Our findings give more insight into older adults' physical resilience, which may improve the prediction of functional recovery and may improve therapeutic decision-making and rehabilitation strategies to improve functional recovery after acute hospitalization. [ABSTRACT FROM AUTHOR]

Background: Count scores, disease clustering, and pairwise associations between diseases remain ubiquitous in multimorbidity research despite two major shortcomings: they yield no insight into plausible mechanisms underlying multimorbidity, and they ignore higher-order interactions such as effect modification. Objectives: We argue that two components are currently missing but vital to develop novel multimorbidity metrics. Firstly, networks should be constructed which consists simultaneously of signs, symptoms, and diseases, since only then could they yield insight into plausible shared biological mechanisms underlying diseases. Secondly, learning pairwise associations is insufficient to fully characterize the correlations in a system. That is, synergistic (e.g., cooperative or antagonistic) effects are widespread in complex systems, where two or more elements combined give a larger or smaller effect than the sum of their individual effects. It can even occur that pairs of symptoms have no pairwise associations whatsoever, but in combination have a significant association. Therefore, higherorder interactions should be included in networks used to study multimorbidity, resulting in so-called hypergraphs. Methods: We illustrate our argument using a synthetic Bayesian Network model of symptoms, signs and diseases, composed of pairwise and higher-order interactions. We simulate network interventions on both individual and population levels and compare the ground-truth outcomes with the predictions from pairwise associations. Conclusion: We find that, when judged purely from the pairwise associations, interventions can have unexpected "side-effects" or the most opportune intervention could be missed. The hypergraph uncovers links missed in pairwise networks, giving a more complete overview of sign and disease associations. [ABSTRACT FROM AUTHOR]

The author looks into the concept of multimorbidity of patients in relation to the improvement of healthcare worldwide. Topics include the importance of understanding the plurality of diseases and its reality, how the operationalization of multimorbidity should be about its causes and consequences, and multimorbidity operationalization as a complex adaptive system's phenomenon.

Background: We aimed to calculate 3-year incidence of multimorbidity, defined as the development of two or more chronic diseases in a population of older people free from multimorbidity at baseline. Secondly, we aimed to identify predictors of incident multimorbidity amongst life-style related indicators, medical conditions and biomarkers. Methods: Data were gathered from 418 participants in the first follow up of the Kungsholmen Project (Stockholm, Sweden, 1991–1993, 78+ years old) who were not affected by multimorbidity (149 had none disease and 269 one disease), including a social interview, a neuropsychological battery and a medical examination. Results: After 3 years, 33.6% of participants who were without disease and 66.4% of those with one disease at baseline, developed multimorbidity: the incidence rate was 12.6 per 100 person-years (95% CI: 9.2–16.7) and 32.9 per 100 person-years (95% CI: 28.1–38.3), respectively. After adjustments, worse cognitive function (OR, 95% CI, for 1 point lower Mini-Mental State Examination: 1.22, 1.00–1.48) was associated with increased risk of multimorbidity among subjects with no disease at baseline. Higher age was the only predictor of multimorbidity in persons with one disease at baseline. Conclusions: Multimorbidity has a high incidence at old age. Mental health-related symptoms are likely predictors of multimorbidity, suggesting a strong impact of mental disorders on the health of older people. [ABSTRACT FROM AUTHOR]

Introduction: Co-occurrence with other chronic diseases may influence the progression of dementia, especially in case of multiple chronic diseases. We aimed to verify whether multimorbidity influenced cognitive and daily functioning during nine years after dementia diagnosis compared with the influence in persons without dementia. Methods: In the Kungsholmen Project, a population-based cohort study, we followed 310 persons with incident dementia longitudinally. We compared their trajectories with those of 679 persons without dementia. Progression was studied for cognition and activities of daily life (ADLs), measured by MMSE and Katz Index respectively. The effect of multimorbidity and its interaction with dementia status was studied using individual growth models. Results: The mean (SD) follow-up time was 4.7 (2.3) years. As expected, dementia related to both the decline in cognitive and daily functioning. Irrespective of dementia status, persons with more diseases had significantly worse baseline daily functioning. In dementia patients having more diseases also related to a significantly faster decline in daily functioning. Due to the combination of lower functioning in ADLs at baseline and faster decline, dementia patients with multimorbidity were about one to two years ahead of the decline of dementia patients without any co-morbidity. In persons without dementia, no significant decline in ADLs over time was present, nor was multimorbidity related to the decline rate. Cognitive decline measured with MMSE remained unrelated to the number of diseases present at baseline. Conclusion: Multimorbidity was related to baseline daily function in both persons with and without dementia, and with accelerated decline in people with dementia but not in non-demented individuals. No relationship of multimorbidity with cognitive functioning was established. These findings imply a strong interconnection between physical and mental health, where the greatest disablement occurs when both somatic and mental disorders are present. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the cost-effectiveness of post-diagnosis dementia treatment and coordination of care by memory clinics compared to general practitioners’ care. Methods: A multicentre randomised trial with 175 community dwelling patients newly diagnosed with mild to moderate dementia, and their informal caregivers, with twelve months’ follow-up. Cost-effectiveness was evaluated from a societal point of view and presented as incremental cost per quality adjusted life year. To establish cost-effectiveness, a cost-utility analysis was conducted using utilities based on the EQ-5D. Uncertainty surrounding the incremental cost-effectiveness ratio (difference in costs divided by difference in effects) was calculated by bootstrapping from the original data. Results: Compared to general practitioners’ care, treatment by the memory clinics was on average €1024 (95% CI: −€7723 to €5674) cheaper, and showed a non-significant decrease of 0.025 (95% CI: −0.114 to 0.064) quality adjusted life years. The incremental cost-effectiveness point estimate from the bootstrap simulation was € 41 442 per QALY lost if one would use memory clinic care instead of general practitioner care. Conclusion: No evidence was found that memory clinics were more cost-effective compared to general practitioners with regard to post-diagnosis treatment and coordination of care of patients with dementia in the first year after diagnosis. Trial Registration: ClinicalTrials.gov NCT00554047 [ABSTRACT FROM AUTHOR]

While designing a trial to evaluate a complex intervention, one may be confronted with the dilemma that randomization at the level of the individual patient risks contamination bias, whereas cluster randomization risks incomparability of study arms and recruitment problems. Literature provides only few solutions to this dilemma and these are not always feasible. As an alternative solution for this dilemma, we developed a new two-stage randomization method called pseudo cluster randomization. In the first stage, the clusters (e.g., recruiting physicians) are randomized into two groups: one group of clusters in which the majority of the participants (e.g., 80%) will receive the experimental treatment; one group of clusters in which the majority will receive the control condition. Following this, the second stage of the randomization involves randomly assigning participants within clusters in the proportions determined by the first stage. This has important advantages. Compared with cluster randomization the potential occurrence of baseline incomparability of treatment arms and poor recruitment is reduced, because the physicians who recruit the participants are unable to know in advance which treatment condition the next participant they recruit will be assigned to. Limiting the exposure of half of the physicians to the innovative intervention lowers risk of contamination bias. When this type of contamination bias is present, pseudo cluster randomization can be more efficient than individual or cluster randomization in that smaller number of study participants is needed to achieve a predefined power. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Cost consciousness in patient care--what is medical education's responsibility?," by M. Cooke in the April 8, 2010 issue.

Objective: caregiver effects of geriatric care models focusing primarily at the patient have not been consistently studied. We studied caregiver effects of a nurse-led comprehensive geriatric evaluation and management (GEM) programme for community-dwelling frail older people that showed--in a randomised comparison with usual care--health-related quality of life benefits for the care receivers. Methods: this randomised trial included 110 caregiver/patient dyads who were followed up for 6 months. Primary analyses were intention-to-treat analyses of caregiver burden assessed with Zarit Burden Interview (ZBI; 0-88; higher means more burden). Preplanned subgroup analyses were conducted for cognition, living arrangement and patient/caregiver co-residence. Results: overall, perceived caregiver burden showed no significant differences between study groups in changes over time. However, perceived burden was at baseline more than eight points higher in caregivers sharing a household with patients (n = 23) compared to caregivers living separately (n = 87). The intervention performed better in caregivers living together with the patient than in caregivers living separately (P for interaction = 0.04). Co-resident caregivers experienced six-Zarit point improvement compared with four-point deterioration in the non-co-resident caregivers. Conclusions: GEM at home benefited patients, but maybe not caregivers. Caregiver effects are related to whether caregivers live with the patient or not. [ABSTRACT FROM AUTHOR]

Abstract: Objective: In the Dutch EASYcare Study, pseudo cluster randomization (PCR) randomized clinicians in two groups (H and L) with a high or a low proportion of the patients of the clinician randomized to intervention or to control arm accordingly. We used PCR because cluster randomization risked selection bias and individual randomization risked contamination. We evaluated the performance of PCR. Study Design and Setting: Clinicians were asked about treatment arm preferences, recruitment behavior, possible contaminating behavior, and what they thought the allocation ratio was. We compared patients'' baseline characteristics and clinicians'' recruitment rates. Results: The groups were comparable at baseline. Clinicians favored the intervention arm (Visual Analogue Scale 14.5 [SD 15.6]; 0–100; 0=strongly favoring intervention arm, 100=strongly favoring usual care arm) and 58% said they would have recruited fewer patients had every participant been allocated to the control group. Sixty five percent of clinicians used intervention elements in control patients. Sixty seven percent of clinicians estimated that a 50:50 allocation ratio was used. Conclusion: The assumptions underlying PCR largely applied in this study. PCR performed satisfactorily without signs of unblinding or selection bias. [Copyright &y& Elsevier]

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]

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]

In some clinical trials, treatment allocation on a patient level is not feasible, and whole groups or clusters of patients are allocated to the same treatment. If, for example, a clinical trial is investigating the efficacy of various patient coaching methods and randomization is done on a patient level, then patients who are receiving different methods may come into contact with each other and influence each other. This would create contamination of the treatment effects. Such bias might be prevented by randomization on the coaches level. The patients of a coach constitute a cluster and all the subjects in that cluster receive the same treatment. Disadvantages of this approach may be reduced statistical efficiency and recruitment bias, as the treatment that a subject will receive is known in advance. Pseudo cluster randomization avoids this, because in pseudo cluster randomization, not everybody in a certain cluster receives the same treatment, just the majority. There are two groups of clusters: in one group the majority of subjects receive treatment A, while a limited number receive treatment B. In the other group of clusters the proportions are reversed. The statistical properties of this method are described. When contamination is present, the method appears to be more efficient than randomization on a patient level or on a cluster level. Copyright © 2005 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Because of their complex clinical presentations and needs frail elderly people require another approach than people who age without many complications. Several inpatient geriatric health services have proven effectiveness in frail persons. However, the wish to live independently and policies that promote independent living as an answer to population aging call for community intervention models for frail elderly people. Maybe models such as preventive home visits, comprehensive geriatric assessment, and intermediate care qualify, but their efficacy is controversial, especially in frail elderly persons living in the community. With the Dutch EASYcare Study Geriatric Intervention Programme (DGIP) we developed a model to study effectiveness of problem based community intervention models in frail elderly people. Methods/Design: DGIP is a community intervention model for frail elderly persons where the GP refers elderly patients with a problem in cognition, mood, behaviour, mobility, and nutrition. A geriatric specialist nurse applies a guideline-based intervention with a limited number of follow up visits. The intervention starts with the application of the EASYcare instrument for geriatric screening. The EASYcare instrument assesses (instrumental) activities of daily life, cognition, mood, and includes a goal setting item. During the intervention the nurse regularly consults the referring GP and a geriatrician. Effects on functional performance (Groningen Activity Restriction Scale), health related quality of life (MOS-20), and carer burden (Zarit Burden Interview) are studied in an observer blinded randomised controlled trial. 151 participants were randomised over two treatment arms - DGIP and regular care - using pseudo cluster randomisation. We are currently performing the follow up visits. These visits are planned three and six months after inclusion. Process measures and cost measures will be recorded. Intention to treat analyses will focus on post intervention differences between treatment groups. Discussion: The design of a trial evaluating the effects of a community intervention model for frail elderly people was presented. The problem-based participant selection procedure satisfied; few patients that the GP referred did not meet our eligibility criteria. The use of standard terminology makes detailed insight into the contents of our intervention possible using terminology others can understand well. [ABSTRACT FROM AUTHOR]

• Late-onset Alzheimer's disease involves interacting mechanisms across multiple scales. • Systems thinking addresses this complexity via conceptual and computational models. • Quantifying extensive models with data enables multi-factor intervention simulations. • Personalized multi-factor interventions: greater efficacy and synergistic benefits. • Systems thinking promotes knowledge synthesis, iterative model-driven data collection. Despite extensive research efforts to mechanistically understand late-onset Alzheimer's disease (LOAD) and other complex mental health disorders, curative treatments remain elusive. We emphasize the multiscale multicausality inherent to LOAD, highlighting the interplay between interconnected pathophysiological processes and risk factors. Systems thinking methods, such as causal loop diagrams and systems dynamic models, offer powerful means to capture and study this complexity. Recent studies developed and validated a causal loop diagram and system dynamics model using multiple longitudinal data sets, enabling the simulation of personalized interventions on various modifiable risk factors in LOAD. The results indicate that targeting factors like sleep disturbance and depressive symptoms could be promising and yield synergistic benefits. Furthermore, personalized interventions showed significant potential, with top-ranked intervention strategies differing significantly across individuals. We argue that systems thinking approaches can open new prospects for multifactorial precision medicine. In future research, systems thinking may also guide structured, model-driven data collection on the multiple interactions in LOAD's complex multicausality, facilitating theory development and possibly resulting in effective prevention and treatment options [ABSTRACT FROM AUTHOR]

This letter comments on the Letter by Pedro Abizanda et al. [ABSTRACT FROM AUTHOR]

Study objectives: While poor sleep quality has been related to increased risk of Alzheimer's disease, long-time shift workers (maritime pilots) did not manifest evidence of early Alzheimer's disease in a recent study. We explored two hypotheses of possible compensatory mechanisms for sleep disruption: Increased efficiency in generating deep sleep during workweeks (model 1) and rebound sleep during rest weeks (model 2). Methods: We used data from ten male maritime pilots (mean age: 51.6±2.4 years) with a history of approximately 18 years of irregular shift work. Subjective sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI). A single lead EEG-device was used to investigate sleep in the home/work environment, quantifying total sleep time (TST), deep sleep time (DST), and deep sleep time percentage (DST%). Using multilevel models, we studied the sleep architecture of maritime pilots over time, at the transition of a workweek to a rest week. Results: Maritime pilots reported worse sleep quality in workweeks compared to rest weeks (PSQI = 8.2±2.2 vs. 3.9±2.0; p<0.001). Model 1 showed a trend towards an increase in DST% of 0.6% per day during the workweek (p = 0.08). Model 2 did not display an increase in DST% in the rest week (p = 0.87). Conclusions: Our findings indicated that increased efficiency in generating deep sleep during workweeks is a more likely compensatory mechanism for sleep disruption in the maritime pilot cohort than rebound sleep during rest weeks. Compensatory mechanisms for poor sleep quality might mitigate sleep disruption-related risk of developing Alzheimer's disease. These results should be used as a starting point for future studies including larger, more diverse populations of shift workers. [ABSTRACT FROM AUTHOR]

The aim of the current study was to investigate the health-related quality of life (HRQol) of the family caregiver in MCI, explore possible determinants and study possible differences with mild dementia. This secondary data analysis included 145 persons with MCI and 154 persons with dementia and their family caregivers from two Dutch cohort studies. HRQoL was measured with the VAS of the EuroQol-5D-3L version. Regressions analyses were conducted to examine potential demographic and clinical determinants of the caregiver's HRQoL. The mean EQ5D-VAS in family caregivers of persons with MCI was 81.1 (SD 15.7), and did not significantly differ from family caregivers in mild dementia (81.9 (SD 13.0)). In MCI, patient measurements were not significantly associated with caregiver mean EQ5D-VAS. Concerning caregiver characteristics, being a spouse and a lower educational level were associated with a lower mean EQ5D-VAS (in a multiple linear regression model: unstandardized B −8.075, p = 0.013 and unstandardized B −6.162, p = 0.037 resp.). In mild dementia, the NPI item irritability showed an association with caregiver EQ5D-VAS in bivariate linear regression analyses. Results indicate that especially family caregiver characteristics seem to influence family caregiver HRQoL in MCI. Future research should include other potential determinants such as burden, coping strategies and relationship quality. [ABSTRACT FROM AUTHOR]

The article discusses research which was conducted to investigate post diagnosis dementia care coordinated by either memory clinics or general practitioners. Researchers conducted a randomised trial of dementia interventions, including medication, nursing home admission, and diary keeping. In the 12 months of follow-up they found that several interventions were more often prescribed or advised by memory clinics compared with general practitioners and that this was possibly because memory clinics are more focused on dementia and have more experience in this field.

The article discusses research being done on cognitive disorder in elderly people. It references the study "Physical and Cognitive Functioning of People Older Than 90 Years: A Comparison of Two Danish Cohorts Born 10 Years Apart," by Kaare Christensen and colleagues in the 2013 issue of "Lancet." The researchers assessed the composite score for attention, verbal memory and word fluency of Danish cohorts of nonagenarians born in 1905 and 1915.

A letter to the editor is presented which is concerned with the development of an instrument which can be used to monitor dementia progression.

The authors reflect on the heat wave in Europe in 2003 which caused an excess mortality in all age groups, with older people as the most affected. They report that frail older people who lived alone, had pre-existing chronic diseases, and were taking drugs, had the highest mortality rate during the heat wave. During heat waves, some of the reported causes of death included dehydration, heat related morbidity, hyperthermia, and heat syncope. The authors also present signs of dehydration and measures needed to reduce heat-related mortality.

Presents an editorial on intermediate care and the need for an international consensus on what constitutes such care. Definition of intermediate care; When it was first introduced in the United Kingdom; Assertion that the many definitions of intermediate care show that the term does not imply a specific, well defined type of health care; Analysis of the consensus process.

The concept of resilience, i.e., the capacity of a system to bounce back after a stressor, is gaining interest across many fields of science, policy, and practice. To date, resilience research in people with cognitive decline has predominantly addressed the early stages of decline. We propose that: (1) resilience is a relevant concept in all stages of cognitive decline; and (2) a socio-ecological, multisystem perspective on resilience is required to advance understanding of, and care and support for people with cognitive decline and their support networks. We substantiate our position with literature and examples. Resilience helps understand differences in response to risk factors of (further) cognitive decline and informs personalised prevention. In a curative context, interventions to strengthen resilience aim to boost recovery from cognitive decline. In care for people with dementia, resilience-focused interventions can strengthen coping mechanisms to maintain functioning and well-being of the individual and their support network. A good example of improving resilience in the social and policy context is the introduction of age-friendly cities and dementia-friendly communities. Good care for people with cognitive decline requires a health and social care system that can adapt to changes in demand. Given the interdependency of resilience at micro-, meso- and macro-levels, an integrative socio-ecological perspective is required. Applying the concept of resilience in the field of cognitive decline opens new horizons for research to improve understanding, predicting, intervening on health and social care needs for the increasing population with cognitive decline. [ABSTRACT FROM AUTHOR]

To evaluate a minute-by-minute monitoring algorithm against a periodic early warning score (EWS) in detecting clinical deterioration and workload. Periodic EWSs suffer from large measurement intervals, causing late detection of deterioration. This might be prevented by continuous vital sign monitoring with a real-time algorithm such as the Visensia Safety Index (VSI). This prospective comparative data modeling cohort study (NCT04189653) compares continuous algorithmic alerts against periodic EWS in continuous monitored medical and surgical inpatients. We evaluated sensitivity, frequency, number of warnings needed to evaluate (NNE) and time of initial alert till escalation of care (EOC): Rapid Response Team activation, unplanned ICU admission, emergency surgery, or death. Also, the percentage of VSI alerting minutes was compared between patients with or without EOC. In 1529 admissions continuous VSI warned for 55% of EOC (95% CI: 45-64%) versus 51% (95% CI: 41-61%) by periodic EWS. NNE for VSI was 152 alerts per detected EOC (95% CI: 114-190) compared to 21 (95% CI: 17-28). It generated 0.99 warnings per day per patient compared to 0.13. Time from detection score till escalation was 8.3 hours (IQR: 2.6-24.8) with VSI versus 5.2 (IQR: 2.7-12.3) hours with EWS (P=0.074). The percentage of warning VSI minutes was higher in patients with EOC than in stable patients (2.36% vs 0.81%, P<0.001). Although sensitivity of detection was not significantly improved continuous vital sign monitoring shows potential for earlier alerts for deterioration compared to periodic EWS. A higher percentage of alerting minutes may indicate risk for deterioration. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: The authors’ first aim was to study the effects of raloxifene and tibolone on body mass density, handgrip strength, and other secondary frailty components. The secondary aim was to compare the effects of raloxifene and tibolone and their safety in older women. Design/Setting/Participants: A randomized, double-blind, double- dummy, placebo-controlled trial conducted in an academic hospital in the Netherlands among 318 community living women aged >70 were randomized; 290 received the allocated intervention: 97 placebo, 101 raloxifene, and 92 tibolone. Interventions: Randomization was made to raloxifene 60 mg, tibolone 1.25 mg, or placebo. Assessments were performed at baseline and after 3, 6, 12, and 24 months. The study was conducted from July 2003 to January 2008. The tibolone group stopped earlier in February 2006, because of results of the Long-Term Intervention on Fractures with Tibolone study, suggesting an increased risk of cerebrovascular accident. Measurements: Primary endpoints were body mass density and handgrip strength. Secondary endpoints were muscle power and strength, mobility measures, body composition, verbal memory, mental processing speed, anxiety, mood, and quality of life. Results: Tibolone and raloxifene had similar body mass density-effect sizes (d = .24–.47), and had no effect on handgrip muscle strength. For the 15 words test the effect on direct recall of concrete and abstract words (d = .40 and d =.27, respectively) and on delayed recall of concrete words (d = .77) were significantly higher in the raloxifene group compared to placebo and to tibolone. In the raloxifene group the health status (EuroQol VAS (0–100) was improved 2.4 points [95% CI 0.5–4.2; P = .012] over 24 months. Conclusion: In women >70 years old, raloxifene and tibolone significantly and similarly increased body mass density but not muscle strength. Raloxifene had also positive effects on verbal memory and health status. New research with selective estrogen receptor modulators like raloxifene might be promising on frailty endpoints in elderly women. Trial registration number: Nederlands Trial Register: 1232 [Copyright &y& Elsevier]

The heterogeneous and multi-factorial nature of dementia requires the consideration of all health aspects when predicting the risk of its development and planning strategies for its prevention. This systematic review of reviews provides a comprehensive synthesis of those factors associated with cognition in the context of dementia, identifying the role of social aspects and evidencing knowledge gaps in this area of research. Systematic reviews and meta-analyses from 2009–2021 were searched for within Medline, PsycINFO, CINAHL Complete, Cochrane, and Epistemonikos. Reviewers independently screened, reviewed, and assessed the records, following the PRISMA-2020 guidelines. From 314 included studies, 624 cognitive-related factors were identified, most of them risk factors (61.2%), mainly belonging to the group of 'somatic comorbidities' (cardiovascular disease and diabetes) and 'genetic predispositions'. The protective factors (20%) were mainly related to lifestyle, pointing to the Mediterranean diet, regular physical activity, and cognitively stimulating activities. Social factors constituted 9.6% of all identified factors. Research on biological and medical factors dominates the reviewed literature. Greater social support and frequent contact may confer some protection against cognitive decline and dementia by delaying its onset or reducing the overall risk; however, overall, our findings are inconsistent. Further research is needed in the fields of lifestyle, psychology, social health, and the protective factors against cognitive decline and dementia. [ABSTRACT FROM AUTHOR]

Purpose: Prehabilitation is increasingly offered to patients with colorectal cancer (CRC) undergoing surgery as it could prevent complications and facilitate recovery. However, implementation of such a complex multidisciplinary intervention is challenging. This study aims to explore perspectives of professionals involved in prehabilitation to gain understanding of barriers or facilitators to its implementation and to identify strategies to successful operationalization of prehabilitation. Methods: In this qualitative study, semi-structured interviews were performed with healthcare professionals involved in prehabilitation for patients with CRC. Prehabilitation was defined as a preoperative program with the aim of improving physical fitness and nutritional status. Parallel with data collection, open coding was applied to the transcribed interviews. The Ottawa Model of Research Use (OMRU) framework, a comprehensive interdisciplinary model guide to promote implementation of research findings into healthcare practice, was used to categorize obtained codes and structure the barriers and facilitators into relevant themes for change. Results: Thirteen interviews were conducted. Important barriers were the conflicting scientific evidence on (cost-)effectiveness of prehabilitation, the current inability to offer a personalized prehabilitation program, the complex logistic organization of the program, and the unawareness of (the importance of) a prehabilitation program among healthcare professionals and patients. Relevant facilitators were availability of program coordinators, availability of physician leadership, and involving skeptical colleagues in the implementation process from the start. Conclusions: Important barriers to prehabilitation implementation are mainly related to the intervention being complex, relatively unknown and only evaluated in a research setting. Therefore, physicians' leadership is needed to transform care towards more integration of personalized prehabilitation programs. Implications for cancer survivors: By strengthening prehabilitation programs and evidence of their efficacy using these recommendations, it should be possible to enhance both the pre- and postoperative quality of life for colorectal cancer patients during survivorship. [ABSTRACT FROM AUTHOR]

Objectives: To explain the heterogeneity in dementia disease trajectory, we studied the influence of changing patient characteristics on disease course by comparing the association of dementia progression with baseline comorbidity and frailty, and with time-varying comorbidity and frailty.Methods: We used individual growth models to study baseline and time-varying associations in newly diagnosed dementia patients (n = 331) followed for 3 years. We measured cognition using the Mini-Mental State Examination (MMSE), daily functioning using the Disability Assessment for Dementia (DAD), frailty using the Fried criteria and comorbidity using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G).Results: Although baseline comorbidity and frailty were associated with decreased daily functioning at diagnosis, their effects clearly diminished over time. In contrast, when incorporating comorbidity and frailty as time-varying covariates, comorbidity was associated with lower daily functioning, and frailty with both lower cognition and daily functioning. Being frail was associated with a 0.9-point lower MMSE score (p = 0.03) and a 14.9-point lower DAD score (p < 0.01). A 1-point increase in CIRS-G score was associated with a 1.1-point lower DAD score (p < 0.01).Conclusions: Time-varying comorbidity and frailty were more consistently associated with dementia disease course than baseline comorbidity and frailty. Therefore, modeling only baseline predictors is insufficient for understanding the course of dementia in a changing patient context. [ABSTRACT FROM AUTHOR]

Objectives: To study the reliability and construct validity of the EASY-Care Two-step Older persons Screening (EASY-Care TOS), a practice-based tool that helps family physicians (FPs) to identify their frail older patients. Study Design and Setting: This validation study was conducted in six FP practices. We determined the construct validity by comparing the results of the EASY-Care TOS with other commonly used frailty constructs [Fried Frailty Criteria (FFC), Frailty Index (FI)] and with other related constructs (ie, multimorbidity, disability, cognition, mobility, mental well-being, and social context). To determine interrater reliability, an independent second EASY-Care TOS assessment was made for a subpopulation. Results: We included 587 older patients (mean age 77 ± 5 years, 56% women). According to EASY-Care TOS, 39.4% of patients were frail. EASY-Care TOS frailty correlated better with FI frailty (0.63) than with FFC frailty (0.52). A high correlation was found with multimorbidity (0.50), disabilities (0.53), and mobility (0.55) and a moderate correlation with cognition (0.31) and mental well-being (0.38). Reliability testing showed 89% agreement (Cohen's κ 0.63) between EASY-Care TOS frailty judgment by two different assessments. Conclusion: EASY-Care TOS correlated well with relevant physical and psychosocial measures. Accordingly, these results show that the EASY-Care TOS identifies patients who have a wide spectrum of interacting problems. [ABSTRACT FROM AUTHOR]

Abstract: A literature search was carried out to summarize the existing scientific evidence concerning occurrence, causes, and consequences of multimorbidity (the coexistence of multiple chronic diseases) in the elderly as well as models and quality of care of persons with multimorbidity. According to pre-established inclusion criteria, and using different search strategies, 41 articles were included (four of these were methodological papers only). Prevalence of multimorbidity in older persons ranges from 55 to 98%. In cross-sectional studies, older age, female gender, and low socioeconomic status are factors associated with multimorbidity, confirmed by longitudinal studies as well. Major consequences of multimorbidity are disability and functional decline, poor quality of life, and high health care costs. Controversial results were found on multimorbidity and mortality risk. Methodological issues in evaluating multimorbidity are discussed as well as future research needs, especially concerning etiological factors, combinations and clustering of chronic diseases, and care models for persons affected by multiple disorders. New insights in this field can lead to the identification of preventive strategies and better treatment of multimorbid patients. [Copyright &y& Elsevier]

Objective: To assess whether a multifactorial fall prevention program was more effective than usual geriatric care in preventing falls and reducing fear of falling in frail community-dwelling older fallers, with and without cognitive impairment, and in alleviating subjective caregiver burden in caregivers. Design, Setting, and Participants: A randomized, 2 parallel-group, single-blind, multicenter trial conducted in 36 pairs of frail fallers, who were referred to a geriatric outpatient clinic after at least 1 fall in the past 6 months, and their informal caregivers. Intervention: Groups of 5 pairs of patients and caregivers received 10 twice-weekly, 2-hour sessions with physical and psychological components and a booster session. Measurements: The primary outcome was the fall rate during a 6-month follow-up. Additionally, we measured fear of falling and subjective caregiver burden. Data on the secondary outcome measures were collected at baseline, directly after, and at 3 and 6 months after the last session of the intervention. Results: Directly after the intervention and at the long-term evaluation, the rate of falls in the intervention group was higher than in the control group, although these differences were not statistically significant (RR = 7.97, P = .07 and RR = 2.12, P = .25, respectively). Fear of falling was higher in the intervention group, and subjective caregiver burden did not differ between groups. Conclusion: Although we meticulously developed this pairwise multifactorial fall prevention program, it was not effective in reducing the fall rate or fear of falling and was not feasible for caregivers, as compared with regular geriatric care. Future research initiatives should be aimed at how to implement the evidence-based principles of geriatric fall prevention for all frail fallers rather than developing more complex interventions for the frailest. [Copyright &y& Elsevier]

Abstract: We describe a modification of a previously described assay for the quantification of α-synuclein in naive cerebrospinal fluid, which allows for a more efficient quantification of α-synuclein. Detection limit of the assay is 3.8ng/ml and the assay is linear until 300ng/ml. Inter-assay and intra-assay coefficients of variation are below 15% in a wide range of concentrations. Mean recovery of the assay is 94%. The 95% upper limit of the reference range (p95) in a group of neurological controls above the age of 45 years is 62ng/ml. This assay can be routinely applied for quantification of α-synuclein in cerebrospinal fluid, but not in serum, and this may serve as a possible biomarker for α-synucleinopathies such as Parkinson''s disease and multiple system atrophy. [Copyright &y& Elsevier]

Due to its cardiovascular effects sedentary behaviour might impact cerebrovascular function in the long term, affecting cerebrovascular regulatory mechanisms and perfusion levels. Consequently this could underly potential structural brain abnormalities associated with cognitive decline. We therefore assessed the association between sedentary behaviour and brain measures of cerebrovascular perfusion and structural abnormalities in community-dwelling older adults. Using accelerometery (GENEActiv) data from The Irish Longitudinal Study on Ageing (TILDA) we categorised individuals by low- and high-sedentary behaviour (≤8 vs >8 hours/day). We examined prefrontal haemoglobin oxygenation levels using Near-Infrared Spectroscopy during rest and after an orthostatic challenge in 718 individuals (66 ± 8 years, 52% female). Global grey matter cerebral blood flow, total grey and white matter volume, total and subfield hippocampal volumes, cortical thickness, and white matter hyperintensities were measured using arterial spin labelling, T1, and FLAIR MRI in 86 individuals (72 ± 6 years, 55% female). While no differences in prefrontal or global cerebral hemodynamics were found between groups, high-sedentary individuals showed lower hippocampal volumes and increased white matter hyperintensities compared to their low-sedentary counterparts. Since these structural cerebral abnormalities are associated with cognitive decline and Alzheimer's disease, future work exploring the causal pathways underlying these differences is needed. [ABSTRACT FROM AUTHOR]

Objectives: Older adults with psychiatric disorders have a substantially lower life expectancy than age-matched controls. Knowledge of risk factors may lead to targeting treatment and interventions to reduce this gap in life expectancy. In this study, we investigated whether frailty independently predicts mortality in older patients following an acute admission to a geriatric psychiatry hospital.Methods: Clinical cohort study with a 5-year follow-up of 120 older patients admitted to a psychiatric hospital between February 2009 and September 2010. On admission, we assessed frailty with a frailty index (FI). We applied Cox regression analyses with time to death as the dependent variable, to examine whether the FI was a predictor for mortality, adjusted for age, sex, level of education, multimorbidity (Cumulative Illness Rating Scale for Geriatrics, CIRS-G scores), functional status (Barthel Index), neuropsychiatric symptoms (NPS), and severity of psychiatric symptoms at admission (Clinical Global Impressions Scale of Severity).Results: Of the 120 patients, 63 (53%) patients were frail (FI ≥ 0.25), and 59 (49%) had died within 5 years. The FI predicted mortality with a hazard ratio (HR) of 1.78 (95% CI, 1.06-2.98) per 0.1 point increase, independent of the covariates. Co-morbidity measured by the CIRS-G and functional status measured by the Barthel Index were not significantly associated.Conclusions: Frailty was a strong predictor of mortality, independent of age, gender, multimorbidity, and functional status. This implies that frailty may be helpful in targeting inpatient psychiatric treatment and aftercare according to patients' life expectancy. [ABSTRACT FROM AUTHOR]

Background: Physicians are cautious to prescribe antihypertensive drugs in frail older adults because of the potential adverse effects, especially in those with cognitive complaints. Lifestyle aspects might provide safe targets to lower blood pressure in older adults.Objective: Our goal was to evaluate the associations between activity patterns and blood pressure in memory clinic patients.Methods: We used an observational cross-sectional study to measure activity patterns with the ActivPAL accelerometer, and simultaneous home blood pressure levels in memory clinic patients (age range 51-87 years old). Office blood pressure was assessed during routine clinical practice.Results: 41 patients (mean age of 74.3 (7.7) years of age, 46% female) were included. Sedentary parameters were associated with higher mean home blood pressure, with the strongest correlation between more prolonged sitting bouts and higher SBP (r = 0.58, p < .0001). Physical activity parameters were negatively associated with mean home blood pressure. Adjusted regression estimates remained significant, showing, e.g., a 4.5 (95% CI = 1.6;7.4) mmHg increase in SBP for every hour of sitting per day and a -1.0 (95% CI = -1.8;-0.2) mmHg decrease in DBP for every additional 1000 steps per day. No strong correlations were found between any of the activity pattern variables and office blood pressure.Conclusion: Associations between activity pattern variables and blood pressure were only found with home blood pressure measurements, not with office measurements. Longitudinal evaluations of these associations are now needed to explore if reducing prolonged sedentary bouts and increasing step count indeed serve as safe targets to lower blood pressure. [ABSTRACT FROM AUTHOR]

Objectives: Frailty, multimorbidity and functional decline predict adverse health outcomes in community dwelling older people and older patients in general hospitals. This study investigates whether these characteristics separately are independent predictors of health outcomes of acute psychiatric hospitalization. Methods: Observational study in a prospectively sampled cohort of older patients, consecutively admitted to a psychiatric hospital. On admission we assessed frailty (Frailty Index and walking speed); multimorbidity (Cumulative Index Rating Scale Geriatrics (CIRS-G)) and functional status (Barthel Index). We used the Clinical Global Impressions of Improvement scale (CGI-I) as the psychiatric outcome measure, and dichotomized discharge destination as overall outcome measure: favourable (able to return home or previous care level) or adverse (death, or move to higher level of residential care). Results: We included 120 patients, 74.6 years (±7.8). 52.5% of the patients was frail (FI ≥0.25). The mean level of the CIRS-G was 13.5 (5.4). Mean CGI-I at discharge was 2.8 (± 1.0), indicating moderate improvement in the psychiatric outcome. Neither FI, CIRS-G, nor Barthel scores were, independent of age, sex and diagnosis, associated with the CGI-I. FI was predictive for adverse discharge destination (OR 1.91, 95%CI 1.09–3.37 per 0.1), as were higher CIRS-G (OR 1.19 95%CI 1.06–1.34, per point) and lower walking speed (OR 1.35 95%CI 1.06–1.72 per 0.1 m/s). Conclusions: Half of our patients were frail and had a high level of multimorbidity. The FI, walking speed and multimorbidity did not predict improvement of psychiatric symptoms at discharge, but independently helped to predict adverse discharge destination. [ABSTRACT FROM AUTHOR]

Background: Geriatricians are often confronted with unexpected health outcomes in older adults with complex multimorbidity. Aging researchers have recently called for a focus on physical resilience as a new approach to explaining such outcomes. Physical resilience, defined as the ability to resist functional decline or recover health following a stressor, is an emerging construct. Methods: Based on an outline of the state‐of‐the‐art in research on the measurement of physical resilience, this article describes what tests to predict resilience can already be used in clinical practice and which innovations are to be expected soon. Results: An older adult's recovery potential is currently predicted by static tests of physiological reserves. Although geriatric medicine typically adopts a multidisciplinary view of the patient and implicitly performs resilience management to a certain extent, clinical management of older adults can benefit from explicitly applying the dynamical concept of resilience. Two crucial leads for advancing our capacity to measure and manage the resilience of individual patients are advocated: first, performing multiple repeated measurements around a stressor can provide insight about the patient's dynamic responses to stressors; and, second, linking psychological and physiological subsystems, as proposed by network studies on resilience, can provide insight into dynamic interactions involved in a resilient response. Conclusion: A big challenge still lies ahead in translating the dynamical concept of resilience into clinical tools and guidelines. As a first step in bridging this gap, this article outlines what opportunities clinicians and researchers can already exploit to improve prediction, understanding, and management of resilience of older adults. J Am Geriatr Soc 67:2650–2657, 2019 [ABSTRACT FROM AUTHOR]

• This meta-analysis suggests that people with both cognitive impairment and physical frailty have the highest dementia risk. • These results support the existence of an interplay between physical and cognitive domains in the development of dementia. • The inclusion of a frailty evaluation in the assessment of people with CIND may enable more reliable dementia prediction. • Studies on mechanisms underlying cognitive and physical decline might open new avenues for dementia prevention and treatment. Cognitive impairment and frailty are important health determinants, independently associated with increased dementia risk. In this meta-analysis we aimed to quantify the association of the co-occurrence of cognitive impairment no dementia (CIND) and physical frailty with incident dementia. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used when reporting this review. We performed a systematic search on PubMed, Web of Science, and Embase databases for relevant articles. Longitudinal studies enrolling individuals with both CIND and physical frailty and reporting dementia incidence were eligible. Pooled estimates were obtained through random effect models and Mantel-Haenszel weighting. Out of 3684 articles, five (14302 participants) were included in the meta-analysis. In comparison to participants free from frailty and CIND, the pooled hazard ratio for dementia was 3.83 (95% confidence interval [CI]: 2.64–5.56) for isolated CIND, 1.47 (95%CI: 0.89–2.40) for isolated physical frailty, and 5.36 (95%CI: 3.26–8.81) for their co-occurrence. The co-occurrence of cognitive impairment and physical frailty is a clinical marker of incident dementia. [ABSTRACT FROM AUTHOR]

Objectives: Previous studies have identified several subgroups (ie, latent trajectories) with distinct disease progression among people with dementia. However, the methods and results were not always consistent. This study aims to perform a coordinated analysis of latent trajectories of cognitive and functional progression in dementia across two datasets.Methods: Included and analyzed using the same statistical approach were 1628 participants with dementia from the US National Alzheimer's Coordinating Center (NACC) and 331 participants with dementia from the Dutch Clinical Course of Cognition and Comorbidity study (4C-Study). Trajectories of cognition and instrumental activities of daily living (IADL) were modeled jointly in a parallel-process growth mixture model.Results: Cognition and IADL tended to decline in unison across the two samples. Slow decline in both domains was observed in 26% of the US sample and 74% of the Dutch sample. Rapid decline in cognition and IADL was observed in 7% of the US sample and 26% of the Dutch sample. The majority (67%) of the US sample showed moderate cognitive decline and rapid IADL decline.Conclusions: Trajectories of slow and rapid dementia progression were identified in both samples. Despite using the same statistical methods, the number of latent trajectories was not replicated and the relative class sizes differed considerably across datasets. These results call for careful consideration when comparing progression estimates in the literature. In addition, the observed discrepancy between cognitive and functional decline stresses the need to monitor dementia progression across multiple domains. [ABSTRACT FROM AUTHOR]

Previous studies have shown large heterogeneity in the progression of dementia, both within and between patients. This heterogeneity offers an opportunity to limit the global and individual burden of dementia through the identification of factors associated with slow disease progression in dementia. We explored the heterogeneity in dementia progression to detect disease, patient, and social context factors related to slow progression. Two longitudinal population-based cohort studies with follow-up across 12 years. 512 people with incident dementia from Stockholm (Sweden) contributed to the Kungsholmen Project and the Swedish National Study of Aging and Care in Kungsholmen. We measured cognition using the Mini-Mental State Examination and daily functioning using the Katz Activities of Daily Living Scale. Latent classes of trajectories were identified using a bivariate growth mixture model. We then used bias-corrected logistic regression to identify predictors of slower progression. Two distinct groups of progression were identified; 76% (n = 394) of the people with dementia exhibited relatively slow progression on both cognition and daily functioning, whereas 24% (n = 118) demonstrated more rapid worsening on both outcomes. Predictors of slower disease progression were Alzheimer's disease (AD) dementia type [odds ratio (OR) 2.07, 95% confidence interval (CI) 1.15-3.71], lower age (OR 0.88, 95% CI 0.83-0.94), fewer comorbidities (OR 0.77, 95% CI 0.66-0.90), and a stronger social network (OR 1.72, 95% CI 1.01-2.93). Lower age, AD dementia type, fewer comorbidities, and a good social network appear to be associated with slow cognitive and functional decline. These factors may help to improve the counseling of patients and caregivers and to optimize the planning of care in dementia. [ABSTRACT FROM AUTHOR]