Optimizing pharmacotherapy on geriatric hospital units in Belgium - a national survey.

OBJECTIVE: Inappropriate prescribing remains highly prevalent on geriatric units. The aim of this investigation, initiated by the Belgian College for Geriatrics, was to evaluate the implementation of strategies to optimize pharmacotherapy on geriatric units in Belgium. METHODS: A literature search was performed to identify strategies to support the appropriate use of medications in very old inpatients. These strategies were subsequently validated based on Delphi consensus rounds and a national survey was developed. Experts were selected by the research team in collaboration with the Belgian College for Geriatrics. The survey was sent to the heads of the geriatric departments of all Belgian hospitals (n = 100). RESULTS: After 3 months a response rate of 55% was achieved. Strategies that were implemented more frequently were the use of electronic prescribing (85%), performing a structured medication review (69%) and providing patient education (76%). In a minority (24%) of hospitals, a clinical pharmacist was directly involved in the multidisciplinary geriatric team. Implementation of clinical decisions support systems (CDSS) was reported by 36% of the hospitals. Educational strategies for healthcare professionals and strategies to optimize transitional care were variable. CONCLUSION: Taking into account the current body of evidence, strategies that include transitional care components, CDSS or ward-based clinical pharmacy services should be further promoted on Belgian geriatric units.

Diagnostic Performance of Automated MRI Volumetry by icobrain dm for Alzheimer's Disease in a Clinical Setting: A REMEMBER Study.

BACKGROUND: Magnetic resonance imaging (MRI) has become important in the diagnostic work-up of neurodegenerative diseases. icobrain dm, a CE-labeled and FDA-cleared automated brain volumetry software, has shown potential in differentiating cognitively healthy controls (HC) from Alzheimer's disease (AD) dementia (ADD) patients in selected research cohorts. OBJECTIVE: This study examines the diagnostic value of icobrain dm for AD in routine clinical practice, including a comparison to the widely used FreeSurfer software, and investigates if combined brain volumes contribute to establish an AD diagnosis. METHODS: The study population included HC (n = 90), subjective cognitive decline (SCD, n = 93), mild cognitive impairment (MCI, n = 357), and ADD (n = 280) patients. Through automated volumetric analyses of global, cortical, and subcortical brain structures on clinical brain MRI T1w (n = 820) images from a retrospective, multi-center study (REMEMBER), icobrain dm's (v.4.4.0) ability to differentiate disease stages via ROC analysis was compared to FreeSurfer (v.6.0). Stepwise backward regression models were constructed to investigate if combined brain volumes can differentiate between AD stages. RESULTS: icobrain dm outperformed FreeSurfer in processing time (15-30 min versus 9-32 h), robustness (0 versus 67 failures), and diagnostic performance for whole brain, hippocampal volumes, and lateral ventricles between HC and ADD patients. Stepwise backward regression showed improved diagnostic accuracy for pairwise group differentiations, with highest performance obtained for distinguishing HC from ADD (AUC = 0.914; Specificity 83.0%; Sensitivity 86.3%). CONCLUSION: Automated volumetry has a diagnostic value for ADD diagnosis in routine clinical practice. Our findings indicate that combined brain volumes improve diagnostic accuracy, using real-world imaging data from a clinical setting.

Dementia, End of Life, and Euthanasia: A Survey Among Dementia Specialists Organized by the Belgian Dementia Council.

BACKGROUND: Palliative care and Advance Care Planning (ACP) are increasingly recommended for an optimal management of late-stage dementia. In Belgium, euthanasia has been decriminalized in 2002 for patients who are "mentally competent" (interpreted as non-demented). It has been suggested that advance directives for euthanasia (ADE) should be made possible for dementia patients. OBJECTIVE: This study presents the results of an internet survey among Belgian dementia specialists. METHODS: In 2013, the Belgian Dementia Council (BeDeCo) organized a debate on end of life decisions in dementia. Participants were medical doctors who are specialists in the dementia field. After the debate, an anonymous internet survey was organized. The participation rate was 55%. The sample was representative of the BeDeCo members. RESULTS: The results showed consensus in favor of palliative care and ACP, although ACP is not systematically addressed in practice. Few patients with dementia have requested euthanasia, but for those who did the participants had agreed to implement it for some patients. A majority of participants (94%) believe that most patients and their families are poorly informed about euthanasia. Although most participants (77%) said they approved the Law on euthanasia, 65% said they were against an extension of the Law to allow ADE for dementia. CONCLUSION: Palliative care and ACP are clearly accepted by professionals, although a gap between recommendation and practice remain. Euthanasia is a much more debated issue, even if a majority of professionals are, in principle, in favor of the current Law and seem to disapprove with a Law change allowing ADE for dementia. A better education for both health professionals and the lay public will be a key element in the future.

A Retrospective Belgian Multi-Center MRI Biomarker Study in Alzheimer's Disease (REMEMBER).

BACKGROUND: Magnetic resonance imaging (MRI) acquisition/processing techniques assess brain volumes to explore neurodegeneration in Alzheimer's disease (AD). OBJECTIVE: We examined the clinical utility of MSmetrix and investigated if automated MRI volumes could discriminate between groups covering the AD continuum and could be used as a predictor for clinical progression. METHODS: The Belgian Dementia Council initiated a retrospective, multi-center study and analyzed whole brain (WB), grey matter (GM), white matter (WM), cerebrospinal fluid (CSF), cortical GM (CGM) volumes, and WM hyperintensities (WMH) using MSmetrix in the AD continuum. Baseline (n = 887) and follow-up (FU, n = 95) T1-weighted brain MRIs and time-linked neuropsychological data were available. RESULTS: The cohort consisted of cognitively healthy controls (HC, n = 93), subjective cognitive decline (n = 102), mild cognitive impairment (MCI, n = 379), and AD dementia (n = 313). Baseline WB and GM volumes could accurately discriminate between clinical diagnostic groups and were significantly decreased with increasing cognitive impairment. MCI patients had a significantly larger change in WB, GM, and CGM volumes based on two MRIs (n = 95) compared to HC (FU>24months, p = 0.020). Linear regression models showed that baseline atrophy of WB, GM, CGM, and increased CSF volumes predicted cognitive impairment. CONCLUSION: WB and GM volumes extracted by MSmetrix could be used to define the clinical spectrum of AD accurately and along with CGM, they are able to predict cognitive impairment based on (decline in) MMSE scores. Therefore, MSmetrix can support clinicians in their diagnostic decisions, is able to detect clinical disease progression, and is of help to stratify populations for clinical trials.

Alzheimer's disease and driving: review of the literature and consensus guideline from Belgian dementia experts and the Belgian road safety institute endorsed by the Belgian Medical Association.

Alzheimer's disease (AD) is a highly prevalent condition and its prevalence is expected to further increase due to the aging of the general population. It is obvious that the diagnosis of AD has implications for driving. Finally, driving discussions are also emotionally charged because driving is associated with independence and personal identity. However, it is not clear how to implement this in clinical practice and the Belgian law on driving is rather vague in its referral to neurodegenerative brain diseases in general nor does it provide clear-cut instructions for dementia or AD compared to for example driving for patients with epilepsy and as such does not prove to be very helpful. The present article reviews what is known from both literature and existing guidelines and proposes a consensus recommendation tailored to the Belgian situation agreed by both AD experts and the Belgian Road Safety Institute endorsed by the Belgian Medical Association. It is concluded that the decision about driving fitness should be considered as a dynamic process where the driving fitness is assessed and discussed early after diagnosis and closely monitored by the treating physician. The diagnosis of AD on itself definitely does not imply the immediate and full revocation of a driving license nor does it implicate a necessary referral for a formal on-road driving assessment. There is no evidence to recommend a reduced exposure or a mandatory co-pilot. A MMSE-based framework to trichotomise AD patients as safe, indeterminate or unsafe is presented. The final decision on driving fitness can only be made after careful history taking and clinical examination, neuropsychological, functional and behavioral evaluation and, only for selected cases, a formal assessment of driving performance.

Dysphagia in elderly nursing home residents with severe cognitive impairment can be attenuated by cervical spine mobilization.

OBJECTIVE: To investigate the feasibility of cervical spine mobilization in elderly dementia patients with dysphagia, and its effect on swallowing capacity. METHODS: Fifteen nursing home residents (9 women, 6 men, age range 77-98 years) with severe dementia (median Mini Mental State Examination score=8/30, percentile (P)25-75=4-13) and known dysphagia participated in a randomized controlled trial with cross-over design. Cervical spine mobilization was administered by trained physiotherapists. Control sessions consisted of socializing visits. Feasibility (attendance, hostility, complications) and maximal swallowing volume (water bolus 1-20 ml) were assessed following one session and one week (3 sessions) of treatment and control. RESULTS: Ninety percent of cervical spine mobilization sessions were completed successfully (3 sessions could not be carried out due to the patient's hostility and 2 due to illness) and no complications were observed. Swallowing capacity improved significantly after cervical spine mobilization (from 3 ml (P25-75=1-10) to 5 ml (P25-75=3-15) after one session p=0.01 and to 10 ml (P25-75=5-20) (+230%) after one week treatment p=0.03) compared with control (no significant changes, difference in evolution after one session between treatment and control, p=0.03). CONCLUSION: Cervical spine mobilization is feasible and can improve swallowing capacity in cognitively impaired residents in nursing homes. Given the acute improvements following treatment, it is probably best provided before meals.

Reaction times and performance variability in normal aging, mild cognitive impairment, and Alzheimer's disease.

This study evaluated whether reaction times (RT) and performance variability are potential markers for the early detection of Alzheimer's disease (AD). Cognitively healthy elderly (n = 218), persons with amnestic MCI (a-MCI) (n = 29) and patients with AD (n = 50) were examined with RT tasks with increasing complexity, subdividing RT into a decision and a movement component. Persons with cognitive deterioration demonstrated more intra-individual variability and more slowing than cognitively healthy elderly. The slowing in AD affects both the cognitive and the motor component, while performance variability mainly affects the cognitive component of the RT. Although in a-MCI not all differences reached statistical significance, primarily the cognitive component of the RT is affected in a-MCI. Intra-individual variability and RT of the complex tasks are the best predictors for a-MCI and AD status, respectively. We conclude that performance variability can be regarded as a useful preclinical marker for AD.

Muscle endurance in elderly nursing home residents is related to fatigue perception, mobility, and circulating tumor necrosis factor-alpha, interleukin-6, and heat shock protein 70.

OBJECTIVES: To explore the relationships between muscle endurance and circulating interleukin (IL)-6, tumor necrosis factor alpha (TNF-alpha), and heat shock protein (Hsp)70 in nursing home residents and to assess how muscle endurance relates to self-perceived fatigue and mobility. DESIGN: Exploratory study. SETTING: Three nursing homes of the Foundation for Psychogeriatrics (Brussels, Belgium). PARTICIPANTS: Seventy-seven residents (53 female and 24 male, mean age 81 +/- 8). MEASUREMENTS: Participants were assessed for muscle endurance (fatigue resistance and grip work); perceived fatigue (visual analogue scale for fatigue); fatigue during daily activities (Mobility-Tiredness Scale); effect of fatigue on quality of life (World Health Organization Quality Of Life questionnaire); mobility (Tinetti Test & Elderly Mobility Scale (EMS)); and circulating IL-6, TNF-alpha, and Hsp70. RESULTS: Residents with better fatigue resistance reported less self-perceived tiredness (P<.05). Similar trends were observed for fatigue during daily activities and for the extent to which fatigue bothered subjects. Higher grip work was associated with less self-perceived fatigue on all fatigue scales (P<.01). Fatigue resistance and grip work were positively related to balance and basic mobility (all P<.01; trend for relationship between fatigue resistance and EMS). Subjects with high IL-6 and Hsp70 showed significantly worse fatigue resistance (P=.007) and muscle work (P=.045) than those with high IL-6 and low Hsp70. In male residents, higher TNF-alpha was related to worse fatigue resistance and grip work (P<.05). CONCLUSION: Elderly nursing home residents complaining of fatigue need to be taken seriously, because they show worse muscle endurance, which is related to poorer mobility. Inflammatory processes involving TNF-alpha and the interaction between IL-6 and Hsp70 are related to poorer muscle endurance in these patients.

Attentional processes discriminate between patients with mild Alzheimer's disease and cognitively healthy elderly.

BACKGROUND: It is generally accepted that Alzheimer's disease (AD) is mainly characterized by memory disorders. Although recent studies also point to an important role of attention deficits early in the disease, this notion has not yet emerged in clinical practice. Our aim was to assess whether attention, quantified by reaction times, can discriminate between patients with mild AD and controls and therefore contribute to clinical diagnosis. METHODS: In a cross-sectional study, 33 patients with mild AD were matched with cognitively healthy elderly controls for age, gender, educational level and depressive mood. Selective attention (SA), alternating attention (AA) and error-rates were measured by a modified reaction time test. RESULTS: Significant differences between both groups were found for all measures. Logistic regression showed that SA (corrected for individual processing speed) and error-rates could correctly classify subjects with an overall hit ratio of 81%. When attention measures were not corrected for individual processing speed, the overall hit ratio improved to 97%. CONCLUSION: SA and AA deteriorate in patients with mild AD and these measures can be used to discriminate between patients and matched controls, independently of depressive mood.

The feasibility of Whole Body Vibration in institutionalised elderly persons and its influence on muscle performance, balance and mobility: a randomised controlled trial [ISRCTN62535013].

BACKGROUND: Fatigue or lack of interest can reduce the feasibility of intensive physical exercise in nursing home residents. Low-volume exercise interventions with similar training effects might be an alternative. The aim of this randomised controlled trial was to investigate the feasibility of Whole Body Vibration (WBV) in institutionalised elderly, and its impact on functional capacity and muscle performance. METHODS: Twenty-four nursing home residents (15 female, 9 male; mean age 77.5 +/- 11.0 years) were randomised (stratification for age, gender and ADL-category) to 6 weeks static WBV exercise (WBV+, N = 13) or control (only static exercise; N = 11). Outcome measures were exercise compliance, timed up-and-go, Tinetti-test, back scratch, chair sit-and-reach, handgrip strength and linear isokinetic leg extension. RESULTS: At baseline, WBV+ and control groups were similar for all outcome variables. Twenty-one participants completed the program and attended respectively 96% and 86% of the exercise sessions for the WBV+ and control groups. Training-induced changes in timed up-and-go and Tinetti-test were better for WBV+ compared to control (p = 0.029 for timed up-and-go, p = 0.001 and p = 0.002 for Tinetti body balance and total score respectively). In an alternative analysis (Worst Rank Score & Last Observation Carried Forward) the differences in change remained significant on the Tinetti body balance and total score. No other significant differences in change between both groups were observed. CONCLUSION: In nursing home residents with limited functional dependency, six weeks static WBV exercise is feasible, and is beneficial for balance and mobility. The supplementary benefit of WBV on muscle performance compared to classic exercise remains to be explored further.