Understanding and predicting the longitudinal course of dementia

PURPOSE OF REVIEW: To date, most research in dementia has focused either on the identification of dementia risk prediction or on understanding changes and predictors experienced by individuals before diagnosis. Despite little is known about how individuals change after dementia diagnosis, there is agreement that changes occur over different time scales and are multidomain. In this study, we present an overview of the literature regarding the longitudinal course of dementia. RECENT FINDINGS: Our review suggests the evidence is scarce and findings reported are often inconsistent. We identified large heterogeneity in dementia trajectories, risk factors considered and modelling approaches employed. The heterogeneity of dementia trajectories also varies across outcomes and domains investigated. SUMMARY: It became clear that dementia progresses very differently, both between and within individuals. This implies an average trajectory is not informative to individual persons and this needs to be taken into account when communicating prognosis in clinical care. As persons with dementia change in many more ways during their patient journey, heterogeneous disease progressions are the result of disease and patient characteristics. Prognostic models would benefit from including variables across a number of domains. International coordination of replication and standardization of the research approach is recommended

De variatie in ouder worden begrijpen en beïnvloeden, dat is onze drijfveer. Een overzicht van het onderzoek van de afdeling Geriatrie van het UMC St Radboud

Bespreking onderzoek De kansen die de grote variatie tussen ouderen biedt, bijvoorbeeld die tussen de zeer succesvol oud geworden Hendrikje van Andel-Schipper (115 jaar) en de gemiddelde verpleeghuispatiënt, vormen de drijfveer voor ons onderzoek. Niet zozeer achteruitgang, maar veel meer heterogeniteit in de wijze waarop de achteruitgang optreedt kenmerkt veroudering

Technical efficiency evaluation of colorectal cancer care for older patients in Dutch hospitals

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

Social Health Is Associated With Structural Brain Changes in Older Adults: The Rotterdam Study

Background: Social health markers have been linked to the development of dementia. We hypothesize that social health affects brain structure and consequently influences cognitive function. We aim to elucidate the cross-sectional and longitudinal associations between social health markers and structural brain changes in older adults in the general population. Methods: Social health markers (loneliness, perceived social support, marital status) were assessed in the Rotterdam Study from 2002 to 2008. Magnetic resonance imaging of the brain was performed repeatedly between 2005 and 2015 for 3737 participants to obtain brain volumetrics, cerebral small vessel disease markers, and white matter microstructural integrity as measures of brain structure. Cross-sectional associations between social health and brain structure were studied using multivariable linear and logistic regression models. Longitudinal associations between baseline social health and changes in brain structure were examined using linear mixed models and generalized estimating equations. Results: Loneliness was associated with smaller white matter volume at baseline (mean difference = −4.63 mL, 95% confidence interval = −8.46 to −0.81). Better perceived social support was associated with larger total brain volume and gray matter volume at baseline and a less steep decrease in total brain volume over time. Better social support was associated with higher global fractional anisotropy and lower mean diffusivity at baseline. Participants who had never been married had a smaller total brain volume (mean difference = −8.27 mL, 95% confidence interval = −13.16 to −3.39) at baseline than married peers. Conclusions: Social health is associated with brain structure. Better perceived social support at baseline was associated with better brain structure over time

Phase Transitions and Resilience in Physical and Psychological Health

Complexity science methods offer new opportunities for prognosis and treatment in healthcare and clinical psychology because of the increasing need for integration of the detailed knowledge of physiological and psychological subsystems and the increasing prevalence of multiple disease conditions in our aging societies. This chapter explains how the frequently occurring acute transitions and related tipping points in physical and mental processes in these populations can be monitored with time series and dynamical indicators of resilience. The authors introduce slowing down of recovery, increase in variance and autocorrelation, and increasing cross-correlation between subsystem time series as valid predictors of the proximity of tipping points in diseases such as depression, heart failure and syncope. Using wearable devices, together with these complex systems analyses, yields new methods of forecasting and may improve resilience of individual persons and their mental or physical (organ) subsystem

Determinants of social health trajectories during the COVID-19 pandemic in older adults: the Rotterdam Study

Objectives: The coronavirus disease-2019 (COVID-19) pandemic and accompanying lockdown restrictions impacted social life significantly. We studied associations of sociodemographic factors, mental and social health markers, and brain structure with social health trajectories during the COVID-19 pandemic. Design: Prospective longitudinal population-based cohort study. Setting: Community-dwelling inhabitants of Rotterdam, the Netherlands. Participants: Repeated questionnaires including questions on social health were sent to Rotterdam Study participants from April 2020 onwards. Social health data at study baseline were available for 5017 participants (mean age: 68.7 ± 11.3; 56.9% women). Measurements: Determinants were assessed in routine Rotterdam Study follow-up (1990-2020), including global brain volumes in a subset of participants (N = 1720). We applied linear mixed models and generalized estimating equations to quantify associations between determinants and trajectories of loneliness, perceived social isolation and social connectedness over three time points from April 22nd to July 31st 2020. Results: Loneliness prevalence was 27.9% in April 2020 versus 12.6% prepandemic. Social isolation (baseline mean 4.7 ± 2.4) and loneliness scores (baseline mean 4.9 ± 1.5) decreased over time, whereas social connectedness trajectories remained stable. Depressive symptoms, female sex, prepandemic loneliness, living alone, and not owning a pet were independently associated with lower social connectedness and higher social isolation and loneliness at COVID-19 baseline, but recovery of social health was similar for all determinants. Larger intracranial volume was associated with higher social connectedness. Conclusions: Despite baseline differences for specific determinants, older adults showed similar recovery of loneliness and social isolation alongside stable social connectedness over time during the pandemic. Social health is multidimensional, especially during a global health crisis

Dynamical indicators of resilience from physiological time series in geriatric inpatients : Lessons learned

The concept of physical resilience may help geriatric medicine objectively assess patients' ability to ‘bounce back’ from future health challenges. Indicators putatively forecasting resilience have been developed under two paradigms with different perspectives: Critical Slowing Down and Loss of Complexity. This study explored whether these indicators validly reflect the construct of resilience in geriatric inpatients. Geriatric patients (n = 121, 60% female) had their heart rate and physical activity continuously monitored using a chest-worn sensor. Indicators from both paradigms were extracted from both physiological signals. Measures of health functioning, concomitant with low resilience, were obtained by questionnaire at admission. The relationships among indicators and their associations with health functioning were assessed by correlation and linear regression analyses, respectively. Greater complexity and higher variance in physical activity were associated with lower frailty (β = −0.28, p = .004 and β = −0.37, p < .001, respectively) and better ADL function (β = 0.23, p = .022 and β = 0.38, p < .001). The associations of physical activity variance with health functioning were not in the expected direction based on Critical Slowing Down. In retrospect, these observations stress the importance of matching the resilience paradigm's assumptions to the homeostatic role of the variable monitored. We present several lessons learned.</p

The association of the STarT Back Screening Tool and type of leg pain with low back pain disability trajectories: a prospective cohort study

Abstract 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

Resilience in Clinical Care: Getting a Grip on the Recovery Potential of Older Adults

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.</p

Meetinstrumenten bij kwetsbare ouderen : EEN PLEIDOOI VOOR MEER STANDAARDISATIE

OBJECTIVE: To determine the frequency and background of the use of assessment instruments for the Comprehensive Geriatric Assessment by clinical geriatricians and internists in geriatric medicine; the secondary aim was to make an inventory of the willingness to standardise the assessment instruments used. DESIGN: A descriptive questionnaire study. METHOD: In December 2016, we sent out a digital questionnaire (Survey Monkey) to all the hospitals in the Netherlands. Respondents were asked which instruments they used for specific domains of the Comprehensive Geriatric Assessment, what their choice of instruments was based on, if these instruments had added value, and if they were prepared to change the instruments they used. RESULTS: We received 66 responses (response: 82%). The most frequently-used instruments were: Mini Mental State Examination in combination with the clock drawing test (21%), Geriatric Depression Scale-15 (45%), Katz Index of Independence in Activities of Daily Living-6 (75%), Lawton and Brody (48%), Mini Nutritional Assessment(-short form) (outpatient; 56%) and Short Nutritional Assessment Questionnaire (inpatient: 36%), Experienced Burden Informal Care (46%), Charlson Comorbidity Index (35%), Timed Up and Go (76%), and the Safety Management System (VMS) fall risk question (21%). The most frequently used instruments were used in a large number of hospitals (35-97%).The variation of tests was the greatest in the domains of cognition, malnutrition, and mobility/physical functioning. Many respondents saw the added value of a consensus set of instruments (median: 70%; interquartile range (IQR): 50-86), and most were willing to change the instruments they use (median: 80%; IQR: 65-90). CONCLUSION: This inventory shows that the instruments used in most domains were reasonably uniform. Taking the willingness to change into account, a national set of basis instruments seems to be an achievable aim