The effect of cognitive impairment on the predictive value of multimorbidity for the increase in disability in the oldest old: the Leiden 85-plus Study

Background: prevention of disability is an important aim of healthcare for older persons. Selection of persons at risk is a first crucial step in this process

What is geriatric rehabilitation and how should it be organized? A Delphi study aimed at reaching European consensus

© 2019, The Author(s). Purpose: Many European countries have developed services to rehabilitate the increasing number of older people who experience an acute or subacute decrease in function after a medical event such as a hip fracture or stroke. However, there are important differences between countries regarding patient selection, organization of services, length of stay, and content of the rehabilitation process. The lack of consensus around, and quality criteria for, geriatric rehabilitation limits opportunities for exchange of best practice and scientific research. Methods: 33 experts, mostly geriatricians with experience in geriatric rehabilitation, from 18 European countries were invited to participate in a modified Delphi study. They were asked to react to 68 statements using a five-point Likert scale. The statements were formulated on the basis of literature review and practice experience, and were initially piloted among Dutch elderly care physicians. Consensus was defined beforehand as an Interquartile Range (IQR) o

Risk stratification and treatment effect of statins in secondary cardiovascular prevention in old age: additive value of N-terminal pro-B-type natriuretic peptide

Background To date, no validated risk scores exist for prediction of recurrence risk or potential treatment effect for older people with a history of a cardiovascular event. Therefore, we assessed predictive values for recurrent cardiovascular disease of models with age and sex, traditional cardiovascular risk markers, and ‘SMART risk score’, all with and without addition of N-terminal pro-B-type natriuretic peptide (NT-proBNP). Treatment effect of pravastatin was assessed across low and high risk groups identified by the best performing models. Design and methods Post-hoc analysis in 2348 participants (age 70–82 years) with a history of cardiovascular disease within the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) study. Composite endpoint was a recurrent cardiovascular event/cardiovascular mortality. Results The models with age and sex, traditional risk markers and SMART risk score had comparable predictive values (area under the curve (AUC) 0.58, 0.61 and 0.59, respectively). Addition of NT-proBNP to these models improved AUCs with 0.07 (p for difference ((pdiff)) = 0.003), 0.05 (pdiff = 0.009) and 0.06 (pdiff < 0.001), respectively. For the model with age, sex and NT-proBNP, the hazard ratio for the composite endpoint in pravastatin users compared with placebo was 0.67 (95% confidence interval 0.49–0.90) for those in the highest third of predicted risk and 0.91 (0.57–1.46) in the lowest third, number needed to treat 12 and 115 (pdiff = 0.038) respectively. Conclusion In secondary cardiovascular prevention in old age addition of NT-proBNP improves prediction of recurrent cardiovascular disease, cardiovascular mortality and treatment effect of pravastatin. A minimal model including age, sex and NT-proBNP predicts as accurately as complex risk models including NT-proBNP

Effectiveness and cost-effectiveness of proactive and multidisciplinary integrated care for older people with complex problems in general practice: An individual participant data meta-analysis

Purpose: to support older people with several healthcare needs in sustaining adequate functioning and independence, more proactive approaches are needed. This purpose of this study is to summarise the (cost-) effectiveness of proactive, multidisciplinary, integrated care programmes for older people in Dutch primary care. Methods design: individual patient data (IPD) meta-analysis of eight clinically controlled trials. Setting: primary care sector. Interventions: combination of (i) identification of older people with complex problems by means of screening, followed by (ii) a multidisciplinary integrated care programme for those identified. Main outcome: activities of daily living, i.e. a change on modified Katz-15 scale between baseline and 1-year follow-up. Secondary outcomes: quality of life (visual analogue scale 0-10), psychological (mental well-being scale Short Form Health Survey (SF)-36) and social well-being (single item, SF-36), quality-adjusted life years (Euroqol-5dimensions-3level (EQ-5D-3L)), healthcare utilisation and cost-effectiveness. Analysis: intention-to-treat analysis, two-stage IPD and subgroup analysis based on patient and intervention characteristics. Results: included were 8,678 participants: median age of 80.5 (interquartile range 75.3; 85.7) years; 5,496 (63.3%) women. On the modified Katz-15 scale, the pooled difference in change between the intervention and control group was -0.01 (95% confidence interval -0.10 to 0.08). No significant differences were found in the other patient outcomes or subgroup analyses. Compared to usual care, the probability of the intervention group to be cost-effective was less than 5%. Conclusion: compared to usual care at 1-year follow-up, strategies for identification of frail older people in primary care combined with a proactive integrated care intervention are probably not (cost-) effective

Abstracts from the 20th International Symposium on Signal Transduction at the Blood-Brain Barriers

https://deepblue.lib.umich.edu/bitstream/2027.42/138963/1/12987_2017_Article_71.pd

Do we AGREE on the targets of antihypertensive drug treatment in older adults: a systematic review of guidelines on primary prevention of cardiovascular diseases.

BACKGROUND translation of the available evidence concerning primary cardiovascular prevention into clinical guidance for the heterogeneous population of older adults is challenging. With this review, we aimed to give an overview of the thresholds and targets of antihypertensive drug therapy for older adults in currently used guidelines on primary cardiovascular prevention. Secondly, we evaluated the relationship between the advised targets and guideline characteristics, including guideline quality. METHODS we systematically searched PubMed, Embase, Emcare and five guideline databases. We selected guidelines with (i) numerical thresholds for the initiation or target values of antihypertensive drug therapy in context of primary prevention (January 2008-July 2020) and (ii) specific advice concerning antihypertensive drug therapy in older adults. We extracted the recommendations and appraised the quality of included guidelines with the AGREE II instrument. RESULTS thirty-four guidelines provided recommendations concerning antihypertensive drug therapy in older adults. Twenty advised a higher target of systolic blood pressure (SBP) for octogenarians in comparison with the general population and three advised a lower target. Over half of the guidelines (n = 18) recommended to target a SBP <150 mmHg in the oldest old, while four endorsed targets of SBP lower than 130 or 120 mmHg. Although many guidelines acknowledged frailty, only three gave specific thresholds and targets. Guideline characteristics, including methodological quality, were not related with the recommended targets. CONCLUSION the ongoing debate concerning targets of antihypertensive treatment in older adults, is reflected in an inconsistency of recommendations across guidelines. Recommended targets are largely set on chronological rather than biological age

Variability in vulnerability assessment of older people by individual general practitioners: a cross-sectional study.

BACKGROUND: In clinical practice, GPs appeared to have an internalized concept of "vulnerability." This study investigates the variability between general practitioners (GPs) in their vulnerability-assessment of older persons. METHODS: Seventy-seven GPs categorized their 75-plus patients (n = 11392) into non-vulnerable, possibly vulnerable, and vulnerable patients. GPs personal and practice characteristics were collected. From a sample of 2828 patients the following domains were recorded: sociodemographic, functional [instrumental activities in daily living (IADL), basic activities in daily living (BADL)], somatic (number of diseases, polypharmacy), psychological (Mini-Mental State Examination, 15-item Geriatric Depression Scale; GDS-15) and social (De Jong-Gierveld Loneliness Scale; DJG). Variability in GPs' assessment of vulnerability was tested with mixed effects logistic regression. P-values for variability (pvar) were calculated by the log-likelihood ratio test. RESULTS: Participating GPs assessed the vulnerability of 10,361 patients. The median percentage of vulnerable patients was 32.0% (IQR 19.5 to 40.1%). From the somatic and psychological domains, GPs uniformly took into account the patient characteristics 'total number of diseases' (OR 1.7, 90% range  = 0, p var = 1), 'polypharmacy' (OR 2.3, 90% range  = 0, p var = 1) and 'GDS-15' (OR 1.6, 90% range  = 0, p var = 1). GPs vary in the way they assessed their patients' vulnerability in the functional domain (IADL: median OR 2.8, 90% range 1.6, p var < 0.001, BADL: median OR 2.4, 90% range 2.9, p var < 0.001) and the social domain (DJG: median OR 1.2, 90% range  = 1.2, p var < 0.001). CONCLUSIONS: GPs seem to share a medical concept of vulnerability, since they take somatic and psychological characteristics uniformly into account in the vulnerability-assessment of older persons. In the functional and social domains, however, variability was found. Vulnerability assessment by GPs might be a promising instrument to select older people for geriatric care if more uniformity could be achieved. TRIAL REGISTRATION: Netherlands Trial Register NTR1946

GPs’ perspectives on preventive care for older people: a focus group study

BACKGROUND: Preventive care traditionally aims to prevent diseases or injuries. For older people, different aims of prevention, such as maintenance of independence and wellbeing, are increasingly important. AIM: To explore GPs’ perspectives on preventive care for older people. DESIGN AND SETTING: Qualitative study comprising six focus groups with GPs in the Netherlands. METHOD: The focus-group discussions with 37 GPs were analysed using the framework analysis method. RESULTS: Whether or not to implement preventive care for older people depends on the patient’s individual level of vitality, as perceived by the GP. For older people with a high level of vitality, GPs confine their role to standardised disease-oriented prevention on a patient’s request; when the vitality levels in older people fall, the scope of preventive care shifts from prevention of disease to prevention of functional decline. For older, vulnerable people, GPs expect most benefit from a proactive, individualised approach, enabling them to live as independently as possible. Based on these perspectives, a conceptual model for preventive care was developed, which describes GPs’ different perspectives toward older people who are vulnerable and those with high levels of vitality. It focuses on five main dimensions: aim of care (prevention of disease versus prevention of functional decline), concept of care (disease model versus functional model), initiator (older persons themselves versus GP), target groups (people with requests versus specified risk groups), and content of preventive care (mainly cardiovascular risk management versus functional decline). CONCLUSION: GPs’ perspectives on preventive care are determined by their perception of the level of vitality of their older patients. Preventive care for older people with high levels of vitality may consist of a standardised disease-oriented approach; those who are vulnerable will need an individualised approach to prevent functional decline

Kaplan-Meier curves, showing cumulative cardiovascular morbidity and mortality.

<p>Kaplan-Meier curves, adjusted for competing risks, showing cumulative cardiovascular morbidity and mortality for tertiles of risk for three different models: traditional risk markers only (left graph), traditional risk markers plus NT-proBNP (middle graph), and traditional risk markers plus all five new markers (a history of major cardiovascular disease, MDRD, CRP, homocysteine and NT-proBNP) (right graph) (N=282).</p