Reviews of individual patient data (IPD) are useful for geriatrics: an overview of available IPD reviews

To determine how many individual patient data (IPD) reviews that included older people were available in MEDLINE and whether the effectiveness of treatments differed between older and younger individuals. Overview of IPD reviews. A MEDLINE search was conducted for IPD reviews of randomized controlled trials published before July 2012. IPD reviews that presented a regression model that included age as a factor or a subgroup analysis of individuals aged 70 and older or in which all participants were aged 70 and older. Whether the IPD reviews reported similar conclusions for the younger and older populations was evaluated. Twenty-six IPD reviews with a subgroup of older individuals and eight reviews with only older individuals were included (median N = 3,351). The most important reason for choosing an IPD review was the ability to perform a subgroup analysis in the older population. Fourteen IPD reviews suggested that older people should receive different treatments from younger people because of differences in effectiveness, six of which indicated that the investigated treatment(s) should be avoided in older adults. IPD review is a valuable approach for generating evidence in older adults. Treatment effects frequently differed between older and younger individuals. Still, IPD results should be applied to older adults cautiously, because they are often excluded from primary trials. The collaborative sharing of raw data should be promoted to improve evidence-based decisions for this grou

Orthostatic hypotension and mortality risk in geriatric outpatients: the impact of duration and magnitude of the blood pressure drop

INTRODUCTION: Orthostatic hypotension is a common condition associated with an increased mortality risk. This study investigates this association specifically in geriatric outpatients and additionally focuses on the duration and magnitude of orthostatic hypotension. METHODS: In this observational prospective cohort study with geriatric outpatients from the Amsterdam Ageing cohort, we differentiated orthostatic hypotension in early orthostatic hypotension (EOH) and delayed/prolonged orthostatic hypotension (DPOH). The magnitude of drop in both SBP and DBP after either 1 or 3 min was quantified. Mortality data was obtained from the Dutch municipal register. Cox proportional hazard models were used to determine the association between orthostatic hypotension and mortality, adjusted for sex and age (model 1), additionally adjusted for orthostatic hypotension-inducing drugs + SBP (model 2) and the presence of cardiovascular disease and diabetes (model 3). Stratified analyses in patients with geriatric deficits were performed. RESULTS: We included 1240 patients (mean age 79.4 ± 6.9 years, 52.6% women). Prevalence of orthostatic hypotension was 443 (34.9%); 148 (11.9%) patients had EOH and 285 (23%) DPOH. DPOH was associated with a higher mortality risk [hazard ratio, 95% CI 1.69 (1.28-2.22)] whereas EOH was not associated with mortality risk. This association did not differ in patients with geriatric deficits. Furthermore, the magnitude of drop in both SBP and DBP was associated with a higher mortality risk. CONCLUSION: The presence of DPOH and the magnitude of both systolic and diastolic orthostatic hypotension are related to an increased mortality risk in geriatric outpatients. Whether the duration of orthostatic hypotension and magnitude of the drop in blood pressure is causally related to mortality risk or whether it is a sign of decreased resilience remains to be elucidated

Development and design of a diagnostic report to support communication in dementia: Co-creation with patients and care partners

Introduction: Clear communication of diagnostic test results and dementia diagnosis is challenging yet important to empower patients and care partners. A personalized diagnostic report could support the communication of dementia diagnostics and aid patients' understanding of diagnosis. In this study, we aimed to design a diagnostic report in co-creation with patients and care partners. Methods: We used a mixed-methods approach, combining surveys with focus groups in iteration. Phase 1 consisted of an international survey assessing needs among patients ( n = 50) and care partners ( n = 46), and phase 2 consisted of focus group meetings ( n = 3) to co-create the content and to hands-on co-design the layout of the diagnostic report with patients ( n = 7) and care partners ( n = 7). Phase 3 validated results from phase 2 in a survey among patients ( n = 28) and care partners ( n = 12), and phase 4 comprised final feedback by dementia (care) experts ( n = 5). Descriptive statistics were used to report quantitative results and directed content analysis was used to analyze qualitative data. Results: Most patients (39/50, 78%) and care partners (38/46, 83%) positively valued a diagnostic report to summarize test results. The report should be brief, straightforward, and comprise results of the diagnostic tests, including brain imaging and information on future expectations. Despite a clear preference for visual display of test results, several visualization options were deemed best and were equally comprehended. Discussion: In this study, we developed a prototype of a personalized patient report through an iterative design process and learned that co-creation is highly valuable to meet the specific needs of end-users

Een vragenlijstonderzoek naar de mening van clinici, patiënten en naasten over computertools in de geheugenpolikliniek: zin of onzin?

Introduction: Computer tools based on artificial intelligence could aid clinicians in memory clinics by supporting diagnostic decision-making and communicating diagnosis and prognosis. We aimed to identify preferences of end-users, and barriers and facilitators for using computer tools in memory clinics. Methods: Between July and October 2020, we invited European clinicians (n=109, age 45±10y; 47% female) to participate in an online questionnaire. A second questionnaire was sent to patients (n=50, age 73±8y, 34% female) with subjective cognitive complaints (SCD, n=21), mild cognitive impairment (MCI, n=16) and dementia (n=13) and care partners (n=46, 65±12y, 54% female). Results: The vast majority (75%) of all participants positively valued the use of computer tools in memory clinics. Facilitating factors included user-friendliness and increased diagnostic accuracy. Barriers included (doubts relating) reliability and validity of the tool and loss of clinical autonomy. The participants believe that tools should be used in addition to the current working method and not as a replacement. Discussion: Our results provide an important step in the iterative process of developing computer tools for memory clinics in co-creation with end-users and could guide successful implementation

Regional MRI volumetry using NeuroQuant versus visual rating scales in patients with cognitive impairment and dementia

Abstract Background and purpose The aims were to compare the novel regional brain volumetric measures derived by the automatic software NeuroQuant (NQ) with clinically used visual rating scales of medial temporal lobe atrophy (MTA), global cortical atrophy‐frontal (GCA‐f), and posterior atrophy (PA) brain regions, assessing their diagnostic validity, and to explore if combining automatic and visual methods would increase diagnostic prediction accuracy. Methods Brain magnetic resonance imaging (MRI) examinations from 86 patients with subjective and mild cognitive impairment (i.e., non‐dementia, n = 41) and dementia (n = 45) from the Memory Clinic at Oslo University Hospital were assessed using NQ volumetry and with visual rating scales. Correlations, receiver operating characteristic analyses calculating area under the curves (AUCs) for diagnostic accuracy, and logistic regression analyses were performed. Results The correlations between NQ volumetrics and visual ratings of corresponding regions were generally high between NQ hippocampi/temporal volumes and MTA (r = −0.72/−0.65) and between NQ frontal volume and GCA‐f (r = −0.62) but lower between NQ parietal/occipital volumes and PA (r = −0.49/−0.37). AUCs of each region, separating non‐dementia from dementia, were generally comparable between the two methods, except that NQ hippocampi volume did substantially better than visual MTA (AUC = 0.80 vs. 0.69). Combining both MRI methods increased only the explained variance of the diagnostic prediction substantially regarding the posterior brain region. Conclusions The findings of this study encourage the use of regional automatic volumetry in locations lacking neuroradiologists with experience in the rating of atrophy typical of neurodegenerative diseases, and in primary care settings

Supplemental Material - Vascular cognitive impairment: When memory loss is not the biggest challenge

Supplemental Material for Vascular cognitive impairment: When memory loss is not the biggest challenge by Sara AJ van de Schraaf, Merel F Smit, Majon Muller, Cees MPM Hertogh, Hanneke FM Rhodius-Meester, Eefje M Sizoo in Dementia.</p

Assessing the views of professionals, patients, and care partners concerning the use of computer tools in memory clinics: International survey study

Background: Computer tools based on artificial intelligence could aid clinicians in memory clinics in several ways, such as by supporting diagnostic decision-making, web-based cognitive testing, and the communication of diagnosis and prognosis. Objective: This study aims to identify the preferences as well as the main barriers and facilitators related to using computer tools in memory clinics for all end users, that is, clinicians, patients, and care partners. Methods: Between July and October 2020, we sent out invitations to a web-based survey to clinicians using the European Alzheimer’s Disease Centers network and the Dutch Memory Clinic network, and 109 clinicians participated (mean age 45 years, SD 10; 53/109, 48.6% female). A second survey was created for patients and care partners. They were invited via Alzheimer Europe, Alzheimer’s Society United Kingdom, Amsterdam Dementia Cohort, and Amsterdam Aging Cohort. A total of 50 patients with subjective cognitive decline, mild cognitive impairment, or dementia (mean age 73 years, SD 8; 17/34, 34% female) and 46 care partners (mean age 65 years, SD 12; 25/54, 54% female) participated in this survey. Results: Most clinicians reported a willingness to use diagnostic (88/109, 80.7%) and prognostic (83/109, 76.1%) computer tools. User-friendliness (71/109, 65.1%); Likert scale mean 4.5, SD 0.7), and increasing diagnostic accuracy (76/109, 69.7%; mean 4.3, SD 0.7) were reported as the main factors stimulating the adoption of a tool. Tools should also save time and provide clear information on reliability and validity. Inadequate integration with electronic patient records (46/109, 42.2%; mean 3.8, SD 1.0) and fear of losing important clinical information (48/109, 44%; mean 3.7, SD 1.2) were most frequently indicated as barriers. Patients and care partners were equally positive about the use of computer tools by clinicians, both for diagnosis (69/96, 72%) and prognosis (73/96, 76%). In addition, most of them thought favorably regarding the possibility of using the tools themselves. Conclusions: This study showed that computer tools in memory clinics are positively valued by most end users. For further development and implementation, it is essential to overcome the technical and practical barriers of a tool while paying utmost attention to its reliability and validity

Memory clinic clinicians’ preferences and needs for communication with patients: A multi-national survey study from EU-FINGERS & LETHE projects

Background: Increased attention to pre-dementia stages of Alzheimer’s disease (AD) creates new challenges for clinician-patient communication. To assist clinicians in these challenges, we aimed to: 1) identify their perspectives on communicating about diagnostic testing, biomarker test results, dementia risk, and prevention, and 2) inventory their need for communication support. Method: Between June and November 2021, 160 memory clinic clinicians from 21 European countries (56% 31-50yrs; 59% female, 14±10yrs of experience) completed a digital survey in which they provided their opinions based on five hypothetical patient cases: 1) AD dementia, 2) Mild Cognitive Impairment (MCI) with positive (+) AD biomarkers, 3) Subjective Cognitive Decline (SCD) with positive AD biomarkers, 4) MCI with negative (-) AD biomarkers, and 5) SCD with negative AD biomarkers. Additionally, we asked which amount and what type of support (online tools and/or skills training) would be appreciated for 10 listed communication skills. Descriptive statistics were used to report characteristics and survey responses. Result: Most clinicians indicated they would communicate syndrome diagnosis (66-88% of clinicians) and biomarker results (97-100%) to all five hypothetical patients. In case of positive biomarkers, clinicians were more hesitant to explicitly mention the presence of AD in the SCD+ case (29%) than in the MCI+ case (68%). Clinicians rather emphasized that it is not yet known what biomarker positivity means for the patient (68% in SCD+ vs. 32% in MCI+). Almost all clinicians reported discussing prognosis/dementia risk (79-98%) and prevention (90-99%), often tailored to patient characteristics and preferences. Of note, more than half of clinicians indicated that they preferred ‘(very) much’ support regarding 9 out of 10 listed communication skills (Figure 1), via online tools (34%), training (13%), or both (32%). Conclusion: European clinicians have a positive attitude towards communicating about early diagnosis of AD, dementia risk, and prevention. Clinicians differ in whether and how they explain the meaning of positive AD biomarkers to patients with SCD or MCI, reflecting the current debate in the field. Moreover, we identified a need for communication support on these topics. Fulfilling clinicians’ needs might help to attune memory clinic care even better to individual patients

MRI Visual Ratings of Brain Atrophy and White Matter Hyperintensities across the Spectrum of Cognitive Decline Are Differently Affected by Age and Diagnosis

Aim: To assess the associations of age and diagnosis with visual ratings of medial temporal lobe atrophy (MTA), parietal atrophy (PA), global cortical atrophy (GCA), and white matter hyperintensities (WMH) and to investigate their clinical value in a large memory clinic cohort.Methods: We included 2,934 patients (age 67 ± 9 years; 1,391 [47%] female; MMSE 24 ± 5) from the Amsterdam Dementia Cohort (1,347 dementia due to Alzheimer's disease [AD]; 681 mild cognitive impairment [MCI]; 906 controls with subjective cognitive decline). We analyzed the effect of age, APOE e4 and diagnosis on visual ratings using linear regression analyses. Subsequently, we compared diagnostic and predictive value in three age-groups (&lt;65 years, 65–75 years, and &gt;75 years).Results: Linear regression analyses showed main effects of age and diagnosis and an interaction age*diagnosis for MTA, PA, and GCA. For MTA the interaction effect indicated steeper age effects in MCI and AD than in controls. PA and GCA increased with age in MCI and controls, while AD patients have a high score, regardless of age. For WMH we found a main effect of age, but not of diagnosis. For MTA, GCA and PA, diagnostic value was best in patients &lt;65 years (optimal cut-off: ≥1). PA and GCA only discriminated in patients &lt;65 years and MTA in patients &lt;75 years. WMH did not discriminate at all. Taking into account APOE did not affect the identified optimal cut-offs. When we used these scales to predict progression in MCI using Cox proportional hazard models, only MTA (cut-off ≥2) had any predictive value, restricted to patients &gt;75 years.Conclusion: Visual ratings of atrophy and WMH were differently affected by age and diagnosis, requiring an age-specific approach in clinical practice. Their diagnostic value seems strongest in younger patients

Slowing: A Vascular Geriatric Syndrome?

Objectives: This study aimed to investigate the interrelation between slowing in walking, thinking and mood, and their relationship with cerebral small vessel disease (CSVD) in a geriatric population. Design: Cross-sectional study. Setting and Participants: 566 geriatric outpatients from the Amsterdam Aging Cohort (49% female; age 79 ±6 years), who visited the Amsterdam UMC geriatric outpatient memory clinic. Methods: Patients underwent a comprehensive geriatric assessment, brain imaging, and a neuropsychological assessment as part of medical care. Three slowing aspects were investigated: gait speed, processing speed, and apathy symptoms (higher scores indicating more advanced slowing). We visually rated CSVD [white matter hyperintensities (WMHs), strategic lacunes, and microbleeds] on brain imaging. Results: Regression analyses showed that slowing in walking (gait speed) was associated with slowing in thinking [processing speed; β = 0.35, 95% confidence interval (CI) 0.22, 0.48] and slowing in mood (apathy symptoms; β = 0.21, 95% CI 0.13, 0.30), independent of important confounders. Large confluent areas of WMH (Fazekas 3) were associated with all slowing aspects: gait speed (β = 0.49, 95% CI 0.28, 0.71), processing speed (β = 0.36, 95% CI 0.19, 0.52) and apathy symptoms (β = 0.30, 95% CI 0.09, 0.51). In addition, in patients with more slowing aspects below predefined cutoffs, severe WMH was more common. Presence of ≥3 microbleeds was associated with apathy symptoms (β = 0.39, 95% CI 0.12, 0.66), whereas lacunes were not associated with slowing. Conclusions and Implications: This study provides evidence that slowing in walking, thinking, and mood are closely related and associated with CSVD. This phenotype or geriatric syndrome could be helpful to identify and characterize patients with CSVD