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BACKGROUND: The prevalence of impaired cognitive functioning in older patients with end stage kidney disease (ESKD) is high. We aim to describe patterns of memory, executive function or psychomotor speed and to identify nephrologic, geriatric and neuroradiologic characteristics associated with cognitive impairment in older patients approaching ESKD who have not yet started with renal replacement therapy (RRT). METHODS: The COPE-study (Cognitive Decline in Older Patients with ESRD) is a prospective cohort study including 157 participants aged 65 years and older approaching ESKD (eGFR ≤20 ml/min/1.73 m2) prior to starting with RRT. In addition to routinely collected clinical parameters related to ESKD, such as vascular disease burden and parameters of metabolic disturbance, patients received a full geriatric assessment, including extensive neuropsychological testing. In a subgroup of patients (n = 93) a brain MRI was performed. RESULTS: The median age was 75.3 years. Compared to the normative data of neuropsychological testing participants memory performance was in the 24th percentile, executive function in the 18th percentile and psychomotor speed in the 20th percentile. Independent associated characteristics of impairment in memory, executive and psychomotor speed were high age, low educational level and low functional status (all p-values < 0.003). A history of vascular disease (p = 0.007) and more white matter hyperintensities on brain MRI (p = 0.013) were associated with a lower psychomotor speed. CONCLUSION: Older patients approaching ESKD have a high prevalence of impaired memory, executive function and psychomotor speed. The patterns of cognitive impairment and brain changes on MRI are suggestive of vascular cognitive impairment. These findings could be of potentially added value in the decision-making process concerning patients with ESKD.
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Encéfalo/diagnóstico por imagem , Cognição , Disfunção Cognitiva , Função Executiva , Falência Renal Crônica , Desempenho Psicomotor , Idoso , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/metabolismo , Disfunção Cognitiva/fisiopatologia , Demência Vascular/diagnóstico , Feminino , Avaliação Geriátrica/métodos , Humanos , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/psicologia , Imageamento por Ressonância Magnética/métodos , Masculino , Países Baixos/epidemiologia , Testes Neuropsicológicos , Estudos ProspectivosRESUMO
Geriatrics continues to draw insufficient numbers of medical students today. Currently, little is known regarding how education can motivate students to choose geriatrics. The authors' aim was to examine geriatrics from the students' perspective to identify elements that can be useful in education and improving attitudes toward, interest in, and knowledge about geriatrics. The authors analyzed narrative reflection essays of 36 students and clarified the themes from the essays during focus group sessions. Four overarching themes that influenced students' perspective on geriatrics were identified: professional identity, perception of geriatrics, geriatric-specific problems, and learning environment. Students have an inaccurate image of clinical practice and the medical professional identity, which has a negative impact on their attitude toward, interest in, and knowledge of geriatrics. Furthermore, this study yielded the important role of the hidden curriculum on professional identity, the novelty of geriatric-specific problems to students, and the importance of educational approach and good role models.
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Atitude , Geriatria/educação , Estudantes de Medicina/psicologia , Educação , Humanos , Narração , Avaliação das NecessidadesRESUMO
This study has two aims: The first aim is to identify core competencies for shared decision making (SDM) with frail older persons, and the second is to determine key elements of a teaching framework, based on the authors' recently developed model for SDM with older patients who are frail. To this end the authors conducted a qualitative inquiry among health professionals (n = 53) and older patients who are frail (n = 16). Participants formulated core competencies and educational needs for SDM with older patients who are frail, which were further explored in the literature. This resulted in practice recommendations and a teaching framework with the following key elements: create a knowledge base for all health professionals, offer practical training, facilitate communication, identify discussion partners, engage patients, and collaborate. The authors' teaching framework for SDM with older patients who are frail may be useful for clinicians, educators, and researchers who aim to promote SDM with older patients who are frail.
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Tomada de Decisões , Fragilidade , Geriatria/educação , Relações Médico-Paciente , Idoso , Educação/métodos , Idoso Fragilizado , Fragilidade/diagnóstico , Fragilidade/terapia , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Participação do PacienteRESUMO
OBJECTIVE: We propose a novel paradigm to predict acute attacks and exacerbations in chronic episodic disorders such as asthma, cardiac arrhythmias, migraine, epilepsy, and depression. A better generic understanding of acute transitions in chronic dynamic diseases is increasingly important in critical care medicine because of the higher prevalence and incidence of these chronic diseases in our aging societies. DATA SOURCES: PubMed, Medline, and Web of Science. STUDY SELECTION: We selected studies from biology and medicine providing evidence of slowing down after a perturbation as a warning signal for critical transitions. DATA EXTRACTION: Recent work in ecology, climate, and systems biology has shown that slowing down of recovery upon perturbations can indicate loss of resilience across complex, nonlinear biologic systems that are approaching a tipping point. This observation is supported by the empiric studies in pathophysiology and controlled laboratory experiments with other living systems, which can flip from one state of clinical balance to a contrasting one. We discuss examples of such evidence in bodily functions such as blood pressure, heart rate, mood, and respiratory regulation when a tipping point for a transition is near. CONCLUSIONS: We hypothesize that in a range of chronic episodic diseases, indicators of critical slowing down, such as rising variance and temporal correlation, may be used to assess the risk of attacks, exacerbations, and even mortality. Identification of such early warning signals over a range of diseases will enhance the understanding of why, how, and when attacks and exacerbations will strike and may thus improve disease management in critical care medicine.
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Doença Crônica , Cuidados Críticos/métodos , Medição de Risco/métodos , Retroalimentação , Humanos , Modelos Biológicos , Fatores de Risco , Índice de Gravidade de DoençaRESUMO
Cerebral autoregulation (CA) is the mechanism that aims to maintain adequate cerebral perfusion during changes in blood pressure (BP). Transfer function analysis (TFA), the most reported method in literature to quantify CA, shows large between-study variability in outcomes. The aim of this study is to investigate the role of measurement artifacts in this variation. Specifically, the role of distortion in the BP and/or CBFV measurementon TFA outcomes was investigated. The influence of three types of artifacts on TFA outcomes was studied: loss of signal, motion artifacts, and baseline drifts. TFA metrics of signals without the simulated artifacts were compared with those of signals with artifacts. TFA outcomes scattered highly when more than 10% of BP signal or over 8% of the CBFV signal was lost, or when measurements contained one or more artifacts resulting from head movement. Furthermore, baseline drift affected interpretation of TFA outcomes when the power in the BP signal was 5 times the power in the LF band. In conclusion, loss of signal in BP and loss in CBFV, affects interpretation of TFA outcomes. Therefore, it is vital to validate signal quality to the defined standards before interpreting TFA outcomes.
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Artefatos , Determinação da Pressão Arterial , Circulação Cerebrovascular , Homeostase , Velocidade do Fluxo Sanguíneo , Pressão Sanguínea , Humanos , Movimento , Processamento de Sinais Assistido por Computador , Estatística como AssuntoRESUMO
OBJECTIVE: Shared decision-making (SDM) is widely recommended as a way to support patients in making healthcare choices. Due to an ageing population, the number of older patients will increase. Existing models for SDM are not sufficient for this patient group, due to their multi-morbidity, the lack of guidelines and evidence applicable to the numerous combinations of diseases. The aim of this study was to gain consensus on a model for SDM in frail older patients with multiple morbidities. METHODS: We used a three-round Delphi study to reach consensus on a model for SDM in older patients with multiple morbidities. The expert panel consisted of 16 patients (round 1), and 59 professionals (rounds 1-3). In round 1, the SDM model was introduced, rounds 2 and 3 were used to validate the importance and feasibility of the SDM model. RESULTS: Consensus for the proposed SDM model as a whole was achieved for both importance (91% panel agreement) and feasibility (76% panel agreement). CONCLUSIONS: SDM in older patients with multiple morbidities is a dynamic process. It requires a continuous counselling dialogue between professional and patient or proxy decision maker. PRACTICE IMPLICATIONS: The developed model for SDM in clinical practice may help professionals to apply SDM in the complex situation of the care for older patients.
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Tomada de Decisões , Técnicas de Apoio para a Decisão , Participação do Paciente , Idoso , Idoso de 80 Anos ou mais , Consenso , Técnica Delphi , Idoso Fragilizado , Geriatria , Humanos , MorbidadeRESUMO
BACKGROUND: In recent years, primary health care for the ageing population has become increasingly complex. AIM: This study sought to explore the views and needs of healthcare professionals and older patients relating to primary care in order to identify focal areas for improving primary health care for older people. DESIGN AND SETTING: This research was structured as a mixed interview study with focus groups and individual interviews. Participants were made up of primary healthcare professionals and older patients. Patients were recruited from five elderly care homes in a small city in the southern part of the Netherlands. METHOD: All interviews were transcribed verbatim and analysed by two individual researchers applying constant comparative analysis. Data collection proceeded until saturation was reached. RESULTS: Participants in the study agreed about the need for primary care for older patients, and showed sympathy with one another's perspectives. They did note, however, a number of obstacles hindering good healthcare provision. The major themes that arose were: 'autonomy and independence', 'organisational barriers', and 'professional expertise'. Participants generally noted that it is important to clarify differences in perspectives about good care between patients and healthcare professionals. CONCLUSION: Effective primary care intervention for older patients requires mutual understanding of the expectations and goals of all parties involved. There are a number of important requirements, especially accessible patient information in the form of care plans; specialist training for nurses and GPs on complex care and multimorbidity; and training on discussing autonomy, goal setting, and shared care. Further improvement in health care for older people and its evaluation research should focus on these requirements.
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Serviços de Saúde para Idosos/normas , Assistência Centrada no Paciente/organização & administração , Atenção Primária à Saúde , Melhoria de Qualidade/organização & administração , Qualidade da Assistência à Saúde/normas , Idoso , Idoso de 80 Anos ou mais , Atitude do Pessoal de Saúde , Comportamento Cooperativo , Pessoas com Deficiência , Feminino , Grupos Focais , Idoso Fragilizado , Avaliação Geriátrica , Pessoal de Saúde , Serviços de Saúde para Idosos/tendências , Humanos , Entrevistas como Assunto , Masculino , Avaliação das Necessidades , Países Baixos/epidemiologia , Assistência Centrada no Paciente/normas , Autonomia Pessoal , Padrões de Prática em Enfermagem , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/normasRESUMO
Given the increasingly aging population, nearly every doctor will encounter elderly adults who present with multiple complex comorbidities that can challenge even experienced physicians. This may explain why many medical students do not have a positive attitude toward elderly adults and find the complexity of their problems overwhelming. It was hypothesized that a recently developed medical school geriatrics course, based on the game GeriatriX and designed specifically to address the complexities associated with decision-making in geriatrics, can have a positive effect on attitudes toward geriatrics and on perceived knowledge of geriatrics. The effects of this game-based course were evaluated as a proof of concept. The assessment was based on the Aging Semantic Differential (ASD) and a validated self-perceived knowledge scale of geriatric topics. The usability of (and satisfaction with) GeriatriX was also assessed using a 5-point Likert scale. After completion of the course, the ASD changed significantly in the geriatrics course group (n = 29; P = .02) but not in a control group that took a neuroscience course (n = 24; P = .30). Moreover, the geriatrics course group had a significant increase in self-perceived knowledge for 12 of the 18 topics (P = .002), whereas in the control group self-perceived knowledge increased significantly for one topic only (sensory impairment) (P = .04). Finally, the geriatrics students reported enjoying GeriatriX. This proof-of-concept study clearly supports the hypothesis that a 4-week course using a modern educational approach such as GeriatriX can improve students' self-perceived knowledge of geriatrics and their attitudes toward elderly adults.
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Instrução por Computador , Geriatria/educação , Ensino/métodos , Estudos Controlados Antes e Depois , Educação de Graduação em Medicina , Avaliação Educacional , Feminino , Humanos , Masculino , Adulto JovemRESUMO
BACKGROUND: Understanding the relationship between vascular disease and Alzheimer's disease (AD) will enhance our insight into this disease and pave the way for novel therapeutic research. Cerebrovascular dysfunction, expressed as impaired cerebral autoregulation and cerebral vasomotor reactivity, has been observed in transgenic mouse models for AD. Translation to human AD is limited and conflicting however. OBJECTIVE: To investigate if impaired cerebral autoregulation and cerebral vasomotor reactivity, found in animal models for AD, are present in human sporadic AD. METHODS: In 12 patients with mild to moderate AD (75 SD 4 yr) and 24 controls matched for age and history of hypertension, all without diabetes, we measured blood pressure (Finapres) and cerebral blood flow-velocity (transcranial Doppler). Cerebral autoregulation was assessed during changes in blood pressure induced by single and repeated sit-stand maneuvers. Cerebral vasomotor reactivity was assessed during hyperventilation and inhalation of 5 % carbon dioxide. RESULTS: During single sit-stands, controls had a 4% (SD 8) decrease in cerebrovascular resistance during a reduction in blood pressure, and an 8 % (SD 11) increase during a rise in blood pressure, indicating normal cerebral autoregulation. These changes were not seen in AD (p=0.04). During repeated sit-stands, blood pressure fluctuated by 20 % of baseline. This led to larger fluctuations in cerebral blood flow in AD (27 (6) %) than in controls (22 (6) %, p < 0.05). Cerebral vasomotor reactivity to hypercapnia was reduced in AD (42.7 % increase in CBFV, versus 79.5 % in controls, p = 0.03). CONCLUSION: Observations of impaired cerebrovascular function (impaired autoregulation and vasoreactivity) in transgenic mouse models for AD were confirmed in patients with sporadic AD.
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Doença de Alzheimer/fisiopatologia , Encéfalo/irrigação sanguínea , Encéfalo/fisiopatologia , Circulação Cerebrovascular/fisiologia , Homeostase , Idoso , Velocidade do Fluxo Sanguíneo , Pressão Sanguínea , Estudos de Casos e Controles , Feminino , Humanos , Hipercapnia/fisiopatologia , Masculino , Movimento/fisiologia , Postura , Sistema Vasomotor/fisiopatologiaRESUMO
The usefulness and effectiveness of specific serious games in the medical domain is often unclear. This is caused by a lack of supporting evidence on validity of individual games, as well as a lack of publicly available information. Moreover, insufficient understanding of design principles among the individuals and institutions that develop or apply a medical serious game compromises their use. This article provides the first consensus-based framework for the assessment of specific medical serious games. The framework provides 62 items in 5 main themes, aimed at assessing a serious game's rationale, functionality, validity, and data safety. This will allow caregivers and educators to make balanced choices when applying a serious game for healthcare purposes. Furthermore, the framework provides game manufacturers with standards for the development of new, valid serious games.
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OBJECTIVE: Medical students often lack training in complex geriatric medical decision making. We therefore developed the serious game, GeriatriX, for training medical decision making with weighing patient preferences, and appropriateness and costs of medical care. We hypothesized that education with GeriatriX would improve the ability to deal with geriatric decision making and also increase cost consciousness. DESIGN: A randomized, controlled pre-post measurement design. PARTICIPANTS: Fifth-year medical students. INTERVENTION: Playing the serious game GeriatriX as an additive to usual geriatric education. MEASUREMENTS: We evaluated the effects of playing GeriatriX on self-perceived knowledge of geriatric themes and the self-perceived competence of weighing patient preferences, appropriateness, and costs of medical care in geriatric decision making. Cost consciousness was evaluated with a postmeasurement to estimate costs of different diagnostic tests. RESULTS: There was a large positive increase in the self-perceived competence of weighing patient preferences, appropriateness, and costs of medical care in the intervention group (n = 71) (effect sizes of 0.7, 1.0, and 1.2, respectively), which was significantly better for the last 2 aspects than in the control group (n = 63). The intervention group performed better on cost consciousness. Although the self-perceived knowledge increased substantially on some geriatric topics, this improvement was not different between the intervention and control groups. CONCLUSIONS: After playing the serious game, GeriatriX, medical students have a higher self-perceived competence in weighing patient preferences, appropriateness, and costs of medical care in complex geriatric medical decision making. Playing GeriatriX also resulted in better cost consciousness. We therefore encourage wider use of GeriatriX to teach geriatrics in medical curricula and its further research on educational and health care outcomes.
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Instrução por Computador , Controle de Custos , Tomada de Decisões , Educação de Graduação em Medicina/métodos , Geriatria/economia , Geriatria/educação , Ensino/métodos , Jogos de Vídeo , Estudos Controlados Antes e Depois , Avaliação Educacional , HumanosRESUMO
BACKGROUND: Normally, standing up causes a blood pressure (BP) drop within 15 seconds, followed by recovery to baseline driven by BP control mechanisms. The prognostic value of this initial BP drop, but also of the recovery hereafter, is unknown. The aim of this study was to examine the prognostic value of these BP characteristics in response to standing. METHODS: In a retrospective cohort study of 238 consecutive patients visiting our falls outpatient clinic, we examined the relation between all-cause mortality and BP decline and recovery directly after active standing up with Cox proportional hazards analyses. RESULTS: Of 238 patients (mean age 78.4 ± 7.8 years), during a median follow-up of 21.0 months, 36 (15%) patients died. Neither absolute nor relative (%) initial BP drop after standing predicted mortality. In contrast, the magnitude of BP recovery 40-60 seconds after standing was associated with mortality, even after adjustment for age, comorbidity, and other baseline characteristics. When systolic BP had recovered to less than 80% of prestanding baseline after 60 seconds of standing, this was a powerful independent predictor of mortality (hazard ratio: 3.00; 95% confidence interval 1.17-7.68). CONCLUSIONS: Failure to recover from BP decline in the first minute after active standing up is associated with excess mortality in falls clinic patients. A recovery of systolic BP to less than 80% of baseline after 60 seconds may be used as an easily available cardiovascular marker for increased mortality risk in older falls clinic patients.
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Acidentes por Quedas/mortalidade , Pressão Sanguínea/fisiologia , Hipotensão Ortostática/fisiopatologia , Postura/fisiologia , Recuperação de Função Fisiológica , Idoso , Causas de Morte/tendências , Feminino , Humanos , Hipotensão Ortostática/mortalidade , Masculino , Países Baixos/epidemiologia , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendênciasRESUMO
OBJECTIVE: Large health care datasets normally have a hierarchical structure, in terms of levels, as the data have been obtained from different practices, hospitals, or regions. Multilevel regression is the technique commonly used to deal with such multilevel data. However, for the statistical analysis of interactions between entities from a domain, multilevel regression yields little to no insight. While Bayesian networks have proved to be useful for analysis of interactions, they do not have the capability to deal with hierarchical data. In this paper, we describe a new formalism, which we call multilevel Bayesian networks; its effectiveness for the analysis of hierarchically structured health care data is studied from the perspective of multimorbidity. METHODS: Multilevel Bayesian networks are formally defined and applied to analyze clinical data from family practices in The Netherlands with the aim to predict interactions between heart failure and diabetes mellitus. We compare the results obtained with multilevel regression. RESULTS: The results obtained by multilevel Bayesian networks closely resembled those obtained by multilevel regression. For both diseases, the area under the curve of the prediction model improved, and the net reclassification improvements were significantly positive. In addition, the models offered considerable more insight, through its internal structure, into the interactions between the diseases. CONCLUSIONS: Multilevel Bayesian networks offer a suitable alternative to multilevel regression when analyzing hierarchical health care data. They provide more insight into the interactions between multiple diseases. Moreover, a multilevel Bayesian network model can be used for the prediction of the occurrence of multiple diseases, even when some of the predictors are unknown, which is typically the case in medicine.
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Teorema de Bayes , Sistemas Computadorizados de Registros Médicos , Probabilidade , Análise de RegressãoRESUMO
To investigate the association of the hypotensive syndromes orthostatic hypotension (OH), postprandial hypotension (PPH), and carotid sinus hypersensitivity (CSH) with cognitive impairment (mild cognitive impairment/dementia). Continuous measurements of blood pressure (Finapres) were performed during active standing, meal test, and carotid sinus massage, among 184 elderly patients presenting with falls. Mild cognitive impairment (MCI) and dementia were diagnosed following a multidisciplinary assessment. The study design was a retrospective cohort study. The OH, PPH, and CSH were observed in 104 (58%), 108 (64%), and 78 (51%) patients, respectively. A total of 79 (43%) patients were cognitively impaired (MCI impairment n = 44; dementia n = 35). The prevalence of cognitive impairment varied little across the hypotensive syndromes (32%-43%) and was similar in patients with and without hypotensive syndromes (P = .59). In this geriatric population with a high prevalence of both hypotensive syndromes and cognitive impairment, patients with one or more hypotensive syndromes were not likely to have cognitive impairment.
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Transtornos Cognitivos/diagnóstico , Demência/diagnóstico , Hipotensão/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Determinação da Pressão Arterial/métodos , Transtornos Cognitivos/epidemiologia , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/epidemiologia , Comorbidade , Demência/epidemiologia , Avaliação Geriátrica , Humanos , Hipotensão/classificação , Hipotensão/epidemiologia , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/epidemiologia , Masculino , Testes Neuropsicológicos , SíndromeRESUMO
OBJECTIVES: Although the course of single diseases can be studied using traditional epidemiologic techniques, these methods cannot capture the complex joint evolutionary course of multiple disorders. In this study, multilevel temporal Bayesian networks were adopted to study the course of multimorbidity in the expectation that this would yield new clinical insight. STUDY DESIGN AND SETTING: Clinical data of patients were extracted from 90 general practice registries in the Netherlands. One and half million patient-years were used for analysis. The simultaneous progression of six chronic cardiovascular conditions was investigated, correcting for both patient and practice-related variables. RESULTS: Cumulative incidence rates of one or more new morbidities rapidly increase with the number of morbidities present at baseline, ranging up to 47% and 76% for 3- and 5-year follow-ups, respectively. Hypertension and lipid disorders, as health risk factors, increase the cumulative incidence rates of both individual and multiple disorders. Moreover, in their presence, the observed cumulative incidence rates of combinations of cardiovascular disorders, that is, multimorbidity differs significantly from the expected rates. CONCLUSION: There are clear synergies between health risks and chronic diseases when multimorbidity within a patient progresses over time. The method used here supports a more comprehensive analysis of such synergies compared with what can be obtained by traditional statistics.