[Geriatric syndromes, multimorbidity and geriatric psychiatry; an integrated perspective]. / Geriatrische syndromen, multimorbiditeit en ouderenpsychiatrie; een geïntegreerd perspectief.

BACKGROUND: The prevalence of geriatric syndromes, frailty and multimorbidity increases in older age, with a negative impact on health outcomes. Little is known on these problems in older adults with psychiatric disorders. AIM: To evaluate the prevalence of geriatric syndromes and multimorbidity in older adults with psychiatric disorders and their impact on treatment outcomes. METHOD: We conducted a pilot study and a case-control study on older adults with medically insufficiently explained symptoms, a prospective cohort study in older adults, acutely admitted to psychiatric wards and a systematic review to evaluate whether geriatric syndromes were considered in RCTs on depression treatment. RESULTS: Unexplained symptoms were often accompanied by frailty, multimorbidity and psychiatric disorders. Older adults who were acutely admitted to psychiatric wards had a high level of multimorbidity, about half of them were frail, and a third undernourished. Frailty and multimorbidity were independent predictors for not being discharged to their own home. Frailty also strongly predicted the 5-year mortality rate. Geriatric syndromes were hardly considered in study design or as secondary outcome in treatment studies on depression in older adults. CONCLUSION: Overall, geriatric problems are highly prevalent among older adults with psychiatric disorders and have a relevant prognostic impact. The complexity of older psychiatric patients is probably best addressed by interdisciplinary, integrated diagnostic and treatment trajectories.

[Atypical clinical picture of COVID-19 in older patients]. / Atypisch beeld van COVID-19 bij oudere patiënten.

Clinical characteristics and outcomes among older patients with a SARS-CoV-2 infection differ greatly from those seen in younger patients. Here we highlight atypical presentations of this fulminant infectious disease COVID-19, based on a clinical case and a cohort of 19 patients admitted to a geriatric ward. The degree of frailty, resilience and number of co-morbidities caused COVID-19 to present as acute geriatric syndrome events such as falls, delirium and dehydration in these patients. Clinical laboratory results considered typical for COVID-19 were present less often in this frail older population. As in other countries, morbidity and mortality is most severe among frail male patients; therefore, assessment of changes suggestive of typical acute geriatric syndromes in frail older patients with chronic diseases should lead to a careful clinical examination for a SARS-CoV-2 infection. Protocols for diagnosis, and contact isolation measures, should take these atypical presentations into account.

[Heterogeneity of delirium cannot be captured by a simple diagnostic instrument]. / Heterogeniteit van delirium is niet te vangen met simpel screeningsinstrument.

The latest criteria for delirium (DSM-5) still encompass a very heterogeneous group of patients, as both risk factors and causes differ greatly between patients. This makes it unlikely that a single biomarker (e.g. an EEG signal) can be a valid and reliable diagnostic tool in clinical practice. Researchers should be very aware of this heterogeneity, as striving for uniform biomarkers would otherwise result in a considerable waste of research effort. In clinical practice, the delineation of delirium syndrome from dementia and coma using these DSM-5 criteria remains challenging. We state that patient outcomes can probably be improved most by interprofessional, personalised management and the monitoring of vulnerable patients during their individual disease trajectories.

[Dementia: growing disaster or declining epidemic?] / Dementie: groeiende ramp of afnemende epidemie?

- There is currently a lot of uncertainty about the future prevalence of dementia. Not only increasing age, but also educational level and lifestyle of the population appear to play a role.- There is little scientific and societal attention for the great uncertainty around average incidence and prevalence estimates for dementia.- When estimating the prognosis of people with dementia, the average disease course is often used as a basis, while this is not at all representative of the individual course of most patients.- The beneficial findings of recent lifestyle intervention studies ask for more targeted prevention strategies for risk groups. There is no standard preventative strategy which works equally well for everyone.- Given the large influence of dementia-related publications on the expectations of people regarding their ageing, it is important to present measures of dispersion alongside all study results.

[A model for shared decision-making with frail older patients: consensus reached using Delphi technique]. / Model voor gezamenlijke besluitvorming met kwetsbare ouderen.

OBJECTIVE: To develop a model for shared decision-making with frail older patients. DESIGN: Online Delphi forum. METHOD: We used a three-round Delphi technique to reach consensus on the structure of a model for shared decision-making with older patients. The expert panel consisted of 16 patients (round 1), and 59 professionals (rounds 1-3). In round 1, the panel of experts was asked about important steps in the process of shared decision-making and the draft model was introduced. Rounds 2 and 3 were used to adapt the model and test it for 'importance' and 'feasibility'. RESULTS: Consensus for the dynamic shared decision-making model as a whole was achieved for both importance (91% panel agreement) and feasibility (76% panel agreement). CONCLUSION: Shared decision-making with older patients is a dynamic process. It requires a continuous supportive dialogue between health care professional and patient.

The effect of an interactive cycling training on cognitive functioning in older adults with mild dementia: study protocol for a randomized controlled trial.

BACKGROUND: To date there is no cure or an effective disease-modifying drug to treat dementia. Available acetylcholine-esterase inhibiting drugs or memantine only produce small benefits on cognitive and behavioural functioning and their clinical relevance remains controversial. Combined cognitive-aerobic interventions are an appealing alternative or add-on to current pharmacological treatments. The primary aim of this study is to investigate the efficacy of a combined cognitive-aerobic training and a single aerobic training compared to an active control group in older adults with mild dementia. We expect to find a beneficial effect on executive functioning in both training regimes, compared to the control intervention, with the largest effect in the combined cognitive-aerobic group. Secondary, intervention effects on cognitive functioning in other domains, physical functioning, physical activity levels, activities of daily living, frailty and quality of life are studied. METHODS: The design is a single-blind, randomized controlled trial (RCT) with three groups: a combined cognitive-aerobic bicycle training (interactive cycling), a single aerobic bicycle training and a control intervention, which consists of stretching and toning exercises. Older adults with mild dementia follow a 12-week training program consisting of three training sessions of 30-40 min per week. The primary study outcome is objective executive functioning measured with a neuropsychological assessment. Secondary measures are objective cognitive functioning in other domains, physical functioning, physical activity levels, activities of daily living, frailty, mood and quality of life. The three groups are compared at baseline, after 6 and 12 weeks of training, and at 24-week follow-up. DISCUSSION: This study will provide novel information on the effects of an interactive cycling training on executive function in older adults with mild dementia. Furthermore, since this study has both a combined cognitive-aerobic training and a single aerobic training group the effectiveness of the different components of the intervention can be identified. The results of this study may be used for physical and mental activity recommendations in older adults with dementia. TRIAL REGISTRATION: The Netherlands National Trial Register NTR5581 . Registered 14 February 2016.

Validation of the Care-Related Quality of Life Instrument in different study settings: findings from The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS).

PURPOSE: Validity is a contextual aspect of a scale which may differ across sample populations and study protocols. The objective of our study was to validate the Care-Related Quality of Life Instrument (CarerQol) across two different study design features, sampling framework (general population vs. different care settings) and survey mode (interview vs. written questionnaire). METHODS: Data were extracted from The Older Persons and Informal Caregivers Minimum DataSet (TOPICS-MDS, www.topics-mds.eu ), a pooled public-access data set with information on >3,000 informal caregivers throughout the Netherlands. Meta-correlations and linear mixed models between the CarerQol's seven dimensions (CarerQol-7D) and caregiver's level of happiness (CarerQol-VAS) and self-rated burden (SRB) were performed. RESULTS: The CarerQol-7D dimensions were correlated to the CarerQol-VAS and SRB in the pooled data set and the subgroups. The strength of correlations between CarerQol-7D dimensions and SRB was weaker among caregivers who were interviewed versus those who completed a written questionnaire. The directionality of associations between the CarerQol-VAS, SRB and the CarerQol-7D dimensions in the multivariate model supported the construct validity of the CarerQol in the pooled population. Significant interaction terms were observed in several dimensions of the CarerQol-7D across sampling frame and survey mode, suggesting meaningful differences in reporting levels. CONCLUSIONS: Although good scientific practice emphasises the importance of re-evaluating instrument properties in individual research studies, our findings support the validity and applicability of the CarerQol instrument in a variety of settings. Due to minor differential reporting, pooling CarerQol data collected using mixed administration modes should be interpreted with caution; for TOPICS-MDS, meta-analytic techniques may be warranted.

Cholinesterase inhibitors and add-on nutritional supplements in Alzheimer's disease: a systematic review of randomized controlled trials.

To date, single drug and nutrient-based interventions have failed to show a clinically relevant effect on Alzheimer's disease (AD). Multidomain interventions may alleviate symptoms and alter the disease course in a synergistic manner. This systematic review examines the effect of adding nutritional supplementation to cholinesterase inhibitors. A systematic PubMed and Cochrane search resulted in nine high quality studies. The studies had low to moderate risk of bias and focused on oxidative stress, homocysteine levels, membrane fluidity, inflammation and acetylcholine levels. Only the use of vitamin E supplements could reduce the rate of functional decline when combined with cholinesterase inhibitors in one study, whereas cognition was not affected in both this and other studies. None of the other nutritional supplements showed convincing evidence of a beneficial effect when combined with cholinesterase inhibitors. This shows that cognitive and functional improvement is difficult to achieve in patients with AD, despite epidemiological data and evidence of biological effects of nutritional supplements. Addressing one disease pathway in addition to cholinesterase inhibitor therapy is probably insufficient to alter the course of the disease. Personalized, multifactorial interventions may be more successful in improving cognition and daily functioning.

[The Ogilvie syndrome in elderly patients with multimorbidity]. / Het Ogilvie-syndroom bij oudere patiënten met multiproblematiek.

Two patients presented with the Ogilvie syndrome which is an acute colonic pseudo-obstruction without any mechanical obstruction. Both patients suffered from multiple medical conditions such as infections, electrolyte disturbances and functional decline.The Ogilvie syndrome is particularly seen in patients with multimorbidity who stay in the hospital or nursing home. The incidence of the Ogilvie syndrome will probably increase because of ageing of our population and will be most prevalent in the frail elderly. The precise mechanism of this disease is still unclear, but there is evidence in the literature that the aetiology is multifactorial and runs via autonomic dysregulation of the colon.Early recognition and appropriate treatment may reduce the risk of complications and limit mortality, also depending on the related comorbidity.

[Reducing fragmentation in the care of frail older people: the successful development and implementation of the Health and Welfare Information Portal]. / Het verminderen van fragmentatie in de zorg voor kwetsbare ouderen: de succesvolle ontwikkeling en implementatie van het Zorg en WelzijnsInfoPortaal.

Our fragmented health care systems are insufficiently equipped to provide frail older people with high quality of care. Therefore, we developed the Health and Welfare Information Portal (ZWIP), an e-health intervention which aims (1) to facilitate self-management by frail older people and informal caregivers and (2) to improve collaboration among professionals. The ZWIP is a personal conference table, accessible through a secure internet connection, for multidisciplinary communication and information exchange for frail older people, their informal caregivers and professionals. After development, the ZWIP was implemented in seven general practices, and this process was evaluated by means of a mixed-methods study. Eventually, 290 frail older people and 169 professionals participated in the ZWIP. Most professionals were positive about its implementation. Facilitators for the implementation were the experienced need for improvement of interprofessional collaboration and the user-friendliness of the ZWIP. Barriers were the low computer-literacy of frail older people, start-up problems, preferring personal contact, and limited use of the ZWIP by other professionals. In sum, this article describes the successful development and implementation of the ZWIP, an e-health intervention which can reduce fragmentation in the care of frail older people.

[Health Council of the Netherlands underestimates interactions in undernutrition in the elderly]. / Gezondheidsraad miskent interacties bij ondervoeding van ouderen.

The Health Council of the Netherlands has recently published a report on undernutrition in the elderly. Undernutrition is a huge problem associated with negative health outcomes, especially in the frail elderly. Although its review of the recent literature is useful, the report does not contribute anything to clinical practice. The point is that evidence for firm conclusions is still lacking, and that most of all more research is needed to really define undernutrition and that RCTs in homogeneous groups of elderly should yield evidence on the most effective treatment strategies in the different populations in old age. This reductionist viewpoint neglects the fact that undernutrition in the elderly is a geriatric syndrome, which is mainly explained by multifactorial aetiology. Therefore, the only way forward is to study and treat undernutrition in older adults by using a broad geriatric perspective, without aiming for the holy grail of the single best evidenced definition or treatment.

Effects of physical exercise therapy on mobility, physical functioning, physical activity and quality of life in community-dwelling older adults with impaired mobility, physical disability and/or multi-morbidity: a meta-analysis.

This is the first meta-analysis focusing on elderly patients with mobility problems, physical disability and/or multi-morbidity. The aim of this study is to assess the effect of physical exercise therapy on mobility, physical functioning, physical activity and quality of life. A broad systematic literature search was performed in the databases PubMed, CINAHL, Embase, PEDro and The Cochrane Library. Relevant study characteristics were reviewed and meta-analyses using standardized mean differences (SMDs) were performed. The results show that physical exercise therapy has a positive effect on mobility (SMD final value: 0.18; 95% CI: 0.05, 0.30; SMD change value: 0.82; 95% CI: 0.54, 1.10) and physical functioning (SMD final value: 0.27; 95% CI: 0.08, 0.46; SMD change value: 2.93; 95% CI: 2.50, 3.36). High-intensity exercise interventions seem to be somewhat more effective in improving physical functioning than low-intensity exercise interventions (SMD final value: 0.22; 95% CI: -0.17, 0.62; SMD change value: 0.38; 95% CI: -0.48, 1.25). These positive effects are of great value for older adults who are already physically impaired. The effect on physical activity and quality of life was not evident and no definite conclusions on the most effective type of physical exercise therapy intervention can be drawn.

Effect of a medical food on body mass index and activities of daily living in patients with Alzheimer's disease: secondary analyses from a randomized, controlled trial.

OBJECTIVES: To investigate the effect of a medical food (Souvenaid) on body mass index (BMI) and functional abilities in patients with mild Alzheimer's disease (AD). DESIGN/SETTING/PARTICIPANTS/INTERVENTION /MEASUREMENTS: These analyses were performed on data from a 12-week, double-blind, randomized, controlled, multicenter, proof-of-concept study with a similarly designed and exploratory 12-week extension period. Patients with mild AD (Mini-Mental State Examination score of 20-26) were randomized to receive either the active product or an iso-caloric control product. While primary outcomes included measures of cognition, the 23-item Alzheimer's Disease Cooperative Study-Activities of Daily Living (ADCS-ADL) scale was included as a secondary outcome. Both ADCS-ADL and BMI were assessed at baseline and Weeks 6, 12 and 24. Data were analyzed using a repeated-measures mixed model. RESULTS: Overall, data suggested an increased BMI in the active versus the control group at Week 24 (ITT: p = 0.07; PP: p = 0.03), but no treatment effect on ADCS-ADL was observed. However, baseline BMI was found to be a significant treatment effect modifier (ITT: p = 0.04; PP: p = 0.05), and an increase in ADCS-ADL was observed at Week 12 in patients with a 'low' baseline BMI (ITT: p = 0.02; PP: p = 0.04). CONCLUSIONS: These data indicate that baseline BMI significantly impacts the effect of Souvenaid on functional abilities. In addition, there was a suggestion that Souvenaid increased BMI.

Efficacy of a medical food on cognition in Alzheimer's disease: results from secondary analyses of a randomized, controlled trial.

OBJECTIVE: To investigate the extent that baseline cognitive impairment and intake adherence affected the 13-item Alzheimer's Disease Assessment Scale - cognitive subscale (ADAS-cog) intervention response of a medical food in Alzheimer's Disease (AD) patients. DESIGN/SETTING/PARTICIPANTS /INTERVENTION/MEASUREMENTS: This analysis was performed on data from a proof-of-concept study, consisting of a 12-week, double-blind, randomized, controlled, multicenter trial, followed by a similarly designed 12-week extension study. Patients with mild AD (Mini-Mental State Examination [MMSE] score of 20-26) were randomized to receive active or control product as a 125 ml daily drink. One of the co-primary outcome measures was the 13-item ADAS-cog. In this analysis, the study population was divided into two subgroups: patients with 'low' baseline ADAS-cog scores (<25.0) and patients with 'high' baseline ADAS-cog scores (≥25.0). Repeated Measures Models (RMM) were used to determine the relationship between ADAS-cog score and intervention. RESULTS: A significant treatment effect (F[1,319]=4.0, p=0.046) was shown in patients with 'high' baseline ADAS-cog, but not in patients with 'low' baseline ADAS-cog (F[1,250]=1.25, p=0.265). Overall, intake adherence was significantly correlated with ADAS-cog improvement in the active product group (correlation coefficient=-0.260; p=0.019), but not the control group. CONCLUSION: These data indicate that baseline ADAS-cog significantly influenced the effect of Souvenaid intervention on ADAS-cog outcome. A higher intake of active study product was also associated with greater cognitive benefit. These findings highlight the potential benefits of Souvenaid in AD patients and warrant confirmation in larger, controlled studies.

Experiences with cerebrospinal fluid analysis in Dutch memory clinics.

BACKGROUND: Evidence on cerebrospinal fluid (CSF) analysis to demonstrate Alzheimer's disease has not yet been implemented in diagnostic guidelines. METHODS: We investigated the use of CSF analysis in a survey amongst all known memory clinics in the Netherlands, of which 85 of 113 (75.2%) responded. RESULTS: Sixty per cent of respondents used CSF analysis in 5% (median) of patients. The analysis almost always confirmed the working diagnosis in 68.4% and sometimes changed it in 28.2%. Complications occurred very infrequently (0%, median) and were mild. Reasons not to perform CSF analysis included the lack of clear recommendations in diagnostic guidelines. CONCLUSIONS: These results ask for a guideline update to clarify the use of CSF analysis as an add-on diagnostic method.

Outcome instruments to measure frailty: a systematic review.

Frailty is one of the greatest challenges for healthcare professionals. The level of frailty depends on several interrelated factors and can change over time while different interventions seem to be able to influence the level of frailty. Therefore, an outcome instrument to measure frailty with sound clinimetric properties is needed. A systematic review on evaluative measures of frailty was performed in the databases PubMed, EMBASE, Cinahl and Cochrane. The results show numerous instruments that measure the level of frailty. This article gives a clear overview of the content of these frailty instruments and describes their clinimetric properties. Frailty instruments, however, are often developed as prognostic instruments and have also been validated as such. The clinimetric properties of these instruments as evaluative outcome measures are unclear.

Assessment of memory function: the relation between daily observation and neuropsychological test performance.

BACKGROUND: The aim of the study was to explore the value of a daily observation scale in the assessment of patients' memory function by nurses on a geriatric ward. METHODS: An observational study of 50 geriatric inpatients was carried out. The relationship between the memory items of the Nurses' Behavioral Rating Scale for Geriatric Inpatients (GIP) and four types of neuropsychological memory tests was examined: visual paired-associate learning (Visual Association Test, VAT), word-list learning (Eight Word Test, 8WT from the Amsterdam Dementia Screening, ADS), and the subtests Route Recall and Story Recall from the Rivermead Behavioural Memory Test (RBMT). Correlations with the overall measures assessing level of dementia such as the Mini-mental State Examination (MMSE), Clinical Dementia Rating scale (CDR) and the 15-item Geriatric Depression Scale (GDS-15) were examined as well. RESULTS: The Pearson's correlation coefficients between GIP and the four memory tests were between 0.45 and 0.71 (p < 0.01). The GIP correlations with the MMSE and CDR were 0.63 and 0.46, respectively (p < 0.01). No significant correlation was found with the GDS-15. Statistically significant differences in GIP memory scores between patients with dementia and non-demented patients were found (p < 0.01). CONCLUSIONS: Results indicate that an observation scale of memory function may have value for providing information about the underlying memory impairment. The results of nurses' observations may be used in triage contributing to the diagnostic process by selecting patients requiring further neuropsychological assessment.

Pseudo cluster randomization: balancing the disadvantages of cluster and individual randomization.

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.