Tailored mental health care after nursing home admission: improving transfers of people with dementia with behavioral problems. An explorative study.

OBJECTIVES: In the Netherlands, many community-dwelling people with dementia and behavioral disturbances and their family caregivers receive mental health care from a community psychiatric nurse (CPN). To promote continuity of care for these persons after moving to a nursing home, a transfer intervention was developed. The aim of this explorative study was to evaluate this intervention and its implementation. METHOD: A qualitative explorative study design was used. CPNs visited professional nursing home carers, people with dementia and family caregivers six weeks after moving, advised on how to manage behavioral problems of their former clients and provided support to family caregivers. Twenty-two interviews were conducted with participants exposed to the intervention (5 CPNs, 5 family and 12 nursing home carers) and with 11 stakeholders (i.e., nursing home and mental health care managers, professional caregivers) to identify facilitators and barriers to the implementation. Data were collected in 2012 and 2013. RESULTS: The follow-up visit at six weeks met the need for background information of new admitted patients and helped family caregivers close off the period prior to the move. It did not meet the original purpose of providing nursing home staff with advice about problem behaviors on time: six weeks after the move was experienced as too late. CONCLUSION: The transfer intervention increased the awareness of nursing home staff about personal and behavioral characteristics of residents with dementia and supported caregivers in coping with the new situation. The timing of the intervention could be improved by scheduling it immediately after the move.

[Causes and consequences of cognitive decline in the very elderly; the 'Leiden 85-plus Study']. / Oorzaken en gevolgen van cognitieve achteruitgang op hoge leeftijd; de 'Leiden 85-plus Studie'.

In view of the absolute and relative increase in the number of oldest old, it is important to identify the causes and consequences of disease in this group. One of the areas of focus in the 'Leiden 85-plus Study', a population-based prospective study amongst 85-year-olds in the Dutch town of Leiden, is therefore to study the causes and consequences of cognitive decline in the very elderly. Cognitive impairment is the main threat to independence in the oldest old; 85-year-old people with impaired cognitive function (prevalence: 35%) have a ten times greater risk of being limited in their activities of daily life. If this cognitive impairment could be prevented, a large proportion of the independence limitations in the general population could be prevented (population attributable risk: 70%). Limitations in cognitive functioning are strongly associated with the incidence of cardiovascular disease, as well as with a lower average HDL-cholesterol concentration and signs of inflammation. Vascular factors appear to be closely related to development of cognitive impairment in very elderly. Therefore, future therapeutic research will have to demonstrate to what extent influencing the cardiovascular risk factors can lead to the prevention of cognitive decline in the very elderly.

Interaction of atherosclerosis and inflammation in elderly subjects with poor cognitive function.

OBJECTIVE: To test the hypothesis that a pro-inflammatory response is associated with cognitive impairment among individuals with cardiovascular disease. METHOD: All 85-year-old inhabitants of Leiden (n = 599) were visited at their place of residence. A history of cardiovascular disease and an EKG were used as indicators of atherosclerosis. Production of the pro-inflammatory cytokine tumor necrosis factor-alpha and the anti-inflammatory cytokine interleukin-10 was assessed in a whole-blood assay using lipopolysaccharide as a stimulus. Global cognitive functioning was determined with the Mini-Mental State Examination (MMSE); attention, cognitive speed, and memory were determined with four neuropsychological tests; and a history of dementia was obtained. RESULTS: In subjects with cardiovascular disease, median MMSE scores were lower in those with a pro-inflammatory response when compared with those with an anti-inflammatory response (p = 0.02). Similar associations were found for the Stroop Test, measuring attention (p < 0.01), the Coding Test measuring cognitive speed (p = 0.02), the Word Learning Test measuring memory (p < 0.01), and the presence of dementia (p = 0.04). The associations remained unaltered after adjustments for possible confounders such as gender, level of education, use of nonsteroidal anti-inflammatory drugs, use of cardiovascular drugs, and cardiovascular risk factors. In contrast, outcomes of the cognitive tests and presence of dementia were not dependent on the inflammatory response when cardiovascular disease was absent. CONCLUSION: The combination of cardiovascular disease and a pro-inflammatory cytokine response may be associated with cognitive impairment and dementia.

Atherosclerosis and cognitive impairment are linked in the elderly. The Leiden 85-plus Study.

Post-mortem analyses suggest that atherosclerosis more often contributes to late-onset dementia than hitherto expected. We set out to further unravel the relation between atherosclerosis and cognitive impairment. We therefore tested the hypothesis that the number of cardiovascular pathologies is positively associated with cognitive impairment in elderly subjects, and that the smaller number of cardiovascular pathologies in women explains the better cognitive function of elderly women. Within the Leiden 85-plus Study, we assessed the atherosclerotic burden by counting the number of cardiovascular pathologies in the medical histories of a population-based sample of 599 subjects aged 85 years (response 87%). Significantly more men than women had a history of cardiovascular pathologies (67% compared to 59%, P<0.001). In addition, cognitive function was assessed. All subjects completed the Mini-Mental State Examination (MMSE). Cognitive speed and memory were determined with specific neuro-psychological tests in those with a MMSE-score above 18 points. There was a highly significant dose-response relationship between the number of cardiovascular pathologies and cognitive impairment for both men and women. The median MMSE-score was 26 points in subjects without cardiovascular disease and decreased to 25 points for subjects who had two or more cardiovascular pathologies (P for trend =0.003). Similar associations were found for cognitive speed but not for memory. Our data confirm that in old age atherosclerosis significantly contributes to cognitive impairment. Since treatments for atherosclerosis appear to be particularly effective in elderly people, we consider our finding of utmost clinical importance in possibly preventing cognitive impairment and late-onset dementia.

Inflammation and stroke: the Leiden 85-Plus Study .

BACKGROUND: Experimental evidence indicates that interleukin-10 (IL-10) deficiency is associated with the development of cardiovascular and cerebrovascular disease. We analyzed the relation between low IL-10 production levels, history of stroke, and incident fatal stroke. SUMMARY OF REPORT: All 85-year-old inhabitants of Leiden, Netherlands (n=599) were visited at their place of residence (response rate, 87%). Production levels of the anti-inflammatory cytokine IL-10 were assessed in a whole blood assay whereby lipopolysaccharide was used as a stimulus. Plasma concentrations of C-reactive protein (CRP) were also used as a marker of inflammation. A history of stroke was obtained at baseline (prevalence, 10%). The number of fatal strokes was prospectively obtained for a median follow-up of 2.6 years (incidence, 1.82 per 100 person-years at risk). Subjects with a history of stroke had significantly lower median IL-10 production levels at baseline than subjects without stroke (558 versus 764 pg/mL; P<0.05). They also had significantly higher median CRP concentrations (6 versus 3 mg/L; P<0.05). The odds ratio for a history of stroke increased to 2.30 (95% CI, 1.12 to 4.72) over strata representing decreasing production levels of IL-10. The relative risk for incident fatal stroke was 2.94 (95% CI, 1.01 to 8.53) when we compared subjects with low or intermediate baseline IL-10 production levels to those with high production levels of IL-10. CONCLUSIONS: Our data support the hypothesis that subjects with low IL-10 production levels have an increased risk of stroke.

Successful aging in the oldest old: Who can be characterized as successfully aged?

BACKGROUND: Successful aging is a worldwide aim, but it is less clear which indicators characterize elderly persons as successfully aged. We explored the meaning of successful aging from 2 perspectives. METHODS: Analysis of data from the first cross-sectional part of the longitudinal Leiden 85-plus Study, conducted in Leiden, the Netherlands. All inhabitants of Leiden aged 85 years were eligible. Data were obtained from 599 participants (response rate, 87%). Successful aging from a public health perspective was defined as a state of being. All participants were classified as successful or not successful based on optimal scores for physical, social, and psychocognitive functioning and on feelings of well-being, using validated quantitative instruments. Qualitative indepth interviews on the perspectives of elderly persons were held with a representative group of 27 participants. RESULTS: Although 45% (267/599) of the participants had optimal scores for well-being, only 13% (79/599) had optimal scores for overall functioning. In total, 10% (58/599) of the participants satisfied all the criteria and could be classified as successfully aged. The qualitative interviews showed that most elderly persons viewed success as a process of adaptation rather than a state of being. They recognized the various domains of successful aging, but valued well-being and social functioning more than physical and psychocognitive functioning. CONCLUSIONS: If successful aging is defined as an optimal state of overall functioning and well-being, only a happy few meet the criteria. However, elderly persons view successful aging as a process of adaptation. Using this perspective, many more persons could be considered to be successfully aged.

Disability in the oldest old: "can do" or "do do"?

OBJECTIVE: To investigate the discrepancies between outcomes for competence (can do) and actual performance (do do) in activities of daily living (ADLs). DESIGN: Baseline measurements of a population-based follow-up study. SETTING: Leiden 85-Plus Study, the Netherlands. PARTICIPANTS: Five hundred and ninety-nine persons, age 85. The response rate was 86%. MEASUREMENTS: Face-to-face interviews. Measurements of competence and actual performance were based on the Groningen Activity Restriction Scale. Help received was assessed for several domains. Prevalence rates for disability were assessed according to the concepts of both competence and actual performance. Analysis was performed separately for basic activities of daily living (BADLs) and instrumental activities of daily living (IADLs). RESULTS: Seventy-seven percent of the oldest old were competent to perform all the BADLs and performed them regularly. Fifteen percent were not competent to perform certain BADLs independently but performed them regularly with help from others. The prevalence of disability defined as inability in one or more BADLs was 22% for women and 10% for men. The prevalence of disability defined as inactivity in one or more BADLs was 16% for women and 17% for men. Only 5% of the oldest old were competent to perform all IADLs and performed them regularly. In spite of being competent, 70% did not perform certain IADLs regularly. The prevalence of disability defined as inability in one or more IADLs was 64% for women and 55% for men. The prevalence of disability defined as inactivity in one or more IADLs was 92% for women and 98% for men. CONCLUSION: The structural discrepancies between the outcomes of competence and actual performance have important consequences when estimating disability in old people. Promoting actual performance in IADLs may reduce disability.

Cognitive function in the oldest old: women perform better than men.

OBJECTIVE: Limited formal education is associated with poor cognitive function. This could explain sex differences in cognitive function in the oldest old. Whether limited formal education explains differences in cognitive function between elderly women and men was explored. METHODS: The Leiden 85-plus Study is a population based study investigating all 85 year old inhabitants of Leiden with an overall response rate of 87%. A sample of 599 participants were visited at their place of residence. The mini mental state examination was completed by all participants. Cognitive speed and memory were determined with four neuropsychological tests in participants with a mini mental state examination score higher than 18 points. RESULTS: The proportion of women with limited formal education was significantly higher than that of men (70% v 53%, p=0.001), but women had better scores for cognitive speed and memory than men (p<0.05). After adjustment for differences in limited formal education and the presence of depressive symptoms, the odds ratio for women to have a higher cognitive speed than men was 1.7 (95% CI; 1.0 to 2.6), and for them to have a better memory the odds ratio was 1.8 (95%CI; 1.2 to 2.7). CONCLUSION: Women have a better cognitive function than men, despite their lower level of formal education. Limited formal education alone, therefore, cannot explain the differences in cognitive function in women and men. These findings support the alternative hypothesis that biological differences, such as atherosclerosis, between women and men account for the sex differences in cognitive decline.

[Daily functioning and health care utilization among persons 85 years old and older]. / Dagelijks functioneren en zorggebruik onder personen van 85 jaar en ouder.

OBJECTIVE: Description of the activities of daily living and the use of care in relation to several determinants in persons aged 85 years and over. DESIGN: Cross-sectional survey. SETTING: General population from the city of Leiden, the Netherlands. METHOD: A representative sample from the inhabitants aged 85 years and over of the city of Leiden was enrolled. A physician visited 239 'oldest old' (response rate 83%) at their places of residence, in 1991/'92. Data were obtained on health (joint disorder, cardiovascular disease, diabetes mellitus, Parkinson's disease; disorders in cognition, eyesight, hearing; limitation of mobility), self care and household activities in daily living and the use of care (informal care by neighbours or family, (geriatric) home help, district nurse, private help). Statistical analysis was performed by non-parametric tests and logistic regression. RESULTS: Of the 'oldest old' 111 (46%) lived independently, and 67 of them (28% of the total group) had no professional help. Almost all 'oldest old' had at least one health disorder. In all, 129 women (77%) and 43 men (61%) had restrictions in basic and (or) instrumental activities of daily living. These restrictions were strongly related to disorders in cognition, vision and mobility, less related to chronic disease and not related to hearing disorders. Restrictions in the activities of daily living were also related to the living condition. This relation was particularly strong for women. Men living without a partner were more likely to be institutionalised. Among the 'oldest old' who lived independently, restrictions in the activities of daily living were related to the use of care, with the exception of privately organised care. CONCLUSION: One out of four persons aged 85 years and over lived without professional help. Marked differences between the sexes were found for the interrelation between activities in daily living and the use of care.