The effect of a nutrient dense drink on mental and physical function in institutionalized elderly people.

OBJECTIVES: To determine whether in the current study the supply of a nutrient dense drink has a positive effect on mental and physical function of institutionalized elderly people. DESIGN: A 24-week, randomized, double-blind, placebo-controlled, parallel-group, intervention trial. SETTING: Homes for the elderly and nursing homes in the Netherlands. PARTICIPANTS: Institutionalized elderly people older than 60 years, with a BMI < or = 30 kg/m2, and a Mini-Mental State Examination score of at least 10 points. INTERVENTION: In addition to their usual diet the participants (n=176) received either a nutrient dense drink or a placebo drink twice a day during 24 weeks. MEASUREMENTS: The functionality measures included cognitive function, mood, physical performance and the ability to perform activities of daily living. RESULTS: In the supplement group a favorable effect of the intervention drink on body weight (1.6 kg difference in change; P = .035), calf circumference (0.9 cm difference in change; P = .048), and blood values (e.g. Hcy decreased from 16.8 to 11.2 mumol/L in the supplement group) was found. In the total group no significant effect was found on functionality outcomes. However, a subgroup of participants with BMI at baseline below 24.4 kg/m2 performed better on the cognitive subscale of Alzheimer's Disease Assessment Scale (P = .09), and its language sub score (P = .01) after 24 weeks of intervention. CONCLUSION: The results in the total group of this trial suggest that the nutritional supplement used in this study improves nutritional status. Furthermore, the results of this trial suggest that it is effective as treatment for decreasing function in a subgroup of institutionalized elderly people with low BMI.

Changes in markers of cobalamin status after cessation of oral B-vitamin supplements in elderly people with mild cobalamin deficiency.

Mildly cobalamin-deficient elderly were supplemented with 1000 microg cobalamin (group C, n=34), 1000 microg cobalamin with 400 microg folic acid (group CF, n=31) or a placebo (n=30) for 6 months. Participants provided one single blood sample 3, 5 or 7 months after cessation of supplementation to monitor early changes in plasma concentrations of cobalamin, holotranscobalamin (holoTC) and methylmalonic acid (MMA). At the end of supplementation (groups C+CF), one participant met our criteria for mild cobalamin deficiency, as did 13, 14 and 43% of the participants assessed at respectively 3, 5 and 7 months post-supplementation. Cobalamin and holoTC declined on average with 47 and 56% relative to concentrations at the end of supplementation for the group assessed at 7 months post-supplementation. Essentially similar declines were observed for those participants assessed at 3 and 5 months post-supplementation. Mean MMA concentrations increased by 15% (P=0.07) in those participants assessed at 3 and 5 months post-supplementation, and increased by 50% (P=0.002) in those participants assessed at 7 months post-supplementation. Considering MMA as a sensitive tissue marker for cobalamin status, oral supplementation may afford adequate cobalamin status for a period of up to 5 months after cessation in the majority of participants.

[Effectiveness of endarterectomy for symptomatic stenosis of the internal carotid artery; more risk factors important than only the severity of the stenosis]. / Effectiviteit van endarteriëctomie voor symptomatische stenose van de A. carotis; meer factoren belangrijk dan alleen de ernst van de stenose.

Carotid endarterectomy prevents ischaemic stroke in patients who have suffered either a transient ischaemic attack (TIA) or a non-disabling ischaemic stroke and are also diagnosed with severe stenosis of the internal carotid artery (ICA). In order to prevent the occurrence ofa single stroke, 6 patients with a symptomatic 70 to 99% ICA stenosis will have to be operated upon. A meta-analysis of individual patient data from 3 randomised trials shows that the decision whether to advise endarterectomy to an individual patient should not be based solely on the degree of the ICA stenosis, but also on the time interval between symptoms and surgery, the type and severity of symptoms and the plaque morphology. In general, endarterectomy is more effective in men than in women, it is very effective in the elderly, and it is even more effective when performed within two weeks of the symptoms occurring. A decision scheme has been set up enabling one to predict the absolute risk of an ipsilateral stroke in the next 5 years in individual patients who have symptomatic ICA stenosis. This is based on 5 factors: sex, age, the most severe symptom in the last 6 months (stroke, TIA, or ischaemic retinopathy), the number of weeks since the last incident and the morphological characteristics of the plaque.

Homocysteine and cognitive function in institutionalised elderly A cross-sectional analysis.

BACKGROUND: Several cross-sectional, case-control and prospective studies revealed a relation between homocysteine and cognitive function or dementia. These studies included either patient populations or healthy, community- dwelling elderly people. AIM OF THE STUDY: In this study we tested the hypothesis that homocysteine was inversely associated with cognitive function in a population of institutionalised elderly (aged >/= 60 y; n = 157). METHODS: For testing this hypothesis baseline data of a recently conducted intervention study in institutionalised elderly (median age 83 years) were used. Cognitive function was evaluated by the cognitive subscale of the Alzheimer's disease Assessment Scale (ADAS-cog). The association between fasting plasma homocysteine level and cognitive function was investigated by multiple linear regression analysis. RESULTS: In the crude model homocysteine concentration was not significantly related to ADAS-cog score (beta = 0.061; p = 0.45). Age was found to be related to ADAS-cog score (beta = 0.161; p < 0.05). Adjusting for age did however not result in a relation between homocysteine and cognitive function. CONCLUSIONS: In our study no association was found between homocysteine and cognitive function in a population of very old institutionalised subjects.

The old lady who liked liquorice: hypertension due to chronic intoxication in a memory-impaired patient.

The authors report an 85-year-old patient admitted because of cognitive impairment. During examination hypertension and hypokalaemia were found. After some time it was discovered that the patient was eating too much liquorice. The case demonstrates that liquorice intoxication should be considered as a cause of hypertension in old age. Furthermore the case demonstrates that missing an intoxication is a pitfall for medical history taking of patients with cognitive impairment.

[Dementia with Lewy bodies; 2 patients with exacerbation due to an atypical antipsychotic, but with a favorable response to the cholinesterase inhibitor rivastigmine]. / Dementie met Lewy-lichaampjes; 2 patiënten met verergering door een atypisch antipsychoticum, maar met een gunstige reactie op de cholinesteraseremmer rivastigmine.

In two patients, men aged 80 and 75 years with cognitive deterioration, hallucinations and parkinsonism, the clinical diagnosis 'dementia with Lewy bodies' was established. Treatment with an atypical antipsychotic, risperidone and olanzapine respectively, resulted in an exacerbation of the parkinsonism. Rivastigmine evidently improved the psychosis, the anxiety and the cognitive, mood and behaviour disorders. Titrated treatment with levodopa improved the mobility without an increase of the psychosis. The treatment of dementia with Lewy bodies is complex. Levodopa can lead to an increase in visual hallucinations. Antipsychotics often cause serious side effects, such as increasing parkinsonism, sedation and cognitive deterioration. Cholinesterase inhibitors such as rivastigmine could possibly provide an alternative treatment for the neuropsychiatric symptoms.

Information for dementia patients and their caregivers: what information does a memory clinic pass on, and to whom?

This study assessed the information provided in a memory clinic and the patient and caregiver factors that influenced the provision of information. The study was part of a larger cross-sectional study of the diagnosis of dementia and satisfaction with information given. The participants were 51 elderly patients suspected of having dementia and living at home together with their caregivers. The main outcome measures were the checklist of information communicated to the patients and caregivers, patients' behavioural problems, patients' instrumental activities of daily living (IADL) problems, and caregivers' sense of competence. The results indicate that basic information about the diagnosis was given to 86% of patients and 88% of caregivers. Specific information about patients' behaviour and professional care was more often given when patients had more cognitive, behavioural, or IADL problems and caregivers had a lower sense of competence. Providing the majority of patients with information is feasible. These results contribute to an explanation of previous findings indicating that caregivers of patients with cognitive problems not related to dementia were less satisfied with the information they received. Adequate information should not only include issues considered relevant by clinicians but should also be tailored to the information needs of patients and caregivers.

Dementia: predictors of diagnostic accuracy and the contribution of diagnostic recommendations.

OBJECTIVES: To explore and quantify the relative contribution of guideline recommendations and other determinants in the family physicianamprsquos diagnostic work-up of patients suspected of dementia. STUDY DESIGN: We prospectively studied 64 family physicians in an Eastern district in the Netherlands who diagnosed dementia according to the national Dutch guidelines in primary care. Their diagnoses were compared with the reference standard embodied by the memory clinic team of the University Medical Center Nijmegen. POPULATION: The physicians evaluated 107 patients older than 55 years suspected of having dementia. OUTCOMES MEASURED: Predictive values of various clinical and demographic parameters were measured in both univariate and multivariate logistic regression analyses. RESULTS: Activities of daily living (ADL) dependency (odds ratio [OR] = 5.3, P =.03), years since symptoms first started (OR = 1.84, P =.03), and the presence of somatic comorbidity (OR = 0.48, P =.02) independently contributed to the prediction of the presence or absence of dementia. The area under the receiver-operating characteristic (ROC) curve for these 3 variables together was 0.79. The ROC area of the family physiciansamprsquo diagnosis to determine the final diagnosis was 0.74. The number of recommendations applied did not additionally contribute to the assessment of the final diagnosis. CONCLUSIONS: The diagnostic accuracy of the family physician was reasonable. For family physicians, ADL dependency is a better predictor of dementia than cognitive impairment. Family physicians should be aware of diagnostic difficulties in patients with somatic comorbidity. We were unable to confirm the diagnostic value of many of the recommendations of dementia guidelines.

The influence of low-, normal-, and high-carbohydrate meals on blood pressure in elderly patients with postprandial hypotension.

BACKGROUND: Postprandial hypotension (PPH) is a common and serious disorder of blood pressure (BP) regulation in elderly people. It has been suggested that primarily the carbohydrate (CH) content of a meal induces the BP decrease. Therefore, we examined the relationship between the CH content of meals and postprandial BP responses in elderly patients diagnosed with PPH. METHODS: Twelve geriatric patients (aged 75 to 91 years; 6 men) who were previously diagnosed with PPH received standardized liquid meals with low- (25 g), normal- (65 g), and high- (125 g) CH content in random order on three separate days. Systolic BP (SBP), diastolic BP, and heart rate were measured every 5 minutes from 20 minutes before until 75 minutes after each meal. Postprandial symptoms were recorded every 15 minutes. RESULTS: The maximum decrease in SBP was significantly smaller after the low-CH meal (-28 +/- 5 mm Hg) than after the normal- (-39 +/- 7 mm Hg) and high-CH meals (-40 +/- 5 mm Hg) (p <.050 between groups). In addition, the duration of PPH was significantly shorter (p <.010), and postprandial symptoms were less frequent and less severe after the low-CH meal. CONCLUSIONS: Reducing the CH amount in meals induces significantly smaller decreases in SBP, shorter duration of PPH, and reduction of PPH-related symptoms. Therefore, limiting the CH content of an elderly patient's meal can be a clinically effective nonpharmacological treatment for PPH in elderly patients and can reduce the risk of developing symptomatic PPH.

Effect of levodopa on orthostatic and postprandial hypotension in elderly Parkinsonian patients.

BACKGROUND: This study describes orthostatic and postprandial hypotension in elderly Parkinsonian patients and evaluates the effect of levodopa therapy on orthostatic and postprandial hypotension in these patients. METHODS: Seventeen elderly patients with a clinical diagnosis of Parkinson's disease or Parkinsonism based on the U.K. Parkinson's Disease Society Brain Bank criteria (age range, 66-84 years) participated in the study. Blood pressure was continuously monitored during standardized standing and meal tests, after starting 125-mg b.i.d. doses of levodopa/benserazide (Madopar) or placebo, in a double-blind, randomized, cross-over design. Seventeen age- and sex-matched healthy subjects served as controls. RESULTS: Orthostatic hypotension was infrequently found in Parkinsonian patients (13%) and healthy subjects (6%; p =.58, between groups), whereas postprandial hypotension was more frequent in Parkinsonian patients (82%) than in healthy subjects (41%; p <.05, between groups). Doses of levodopa/benserazide, administered 2 times per day, did not result in significantly larger blood pressure decreases after standing or eating, or in higher frequencies of orthostatic or postprandial hypotension in the Parkinsonian group. Postprandial hypotension was related to disease severity (r = -.56, p <.05). CONCLUSIONS: Postprandial hypotension, but not orthostatic hypotension, was more common in elderly Parkinsonian patients than in healthy subjects. Therapy with 125-mg b.i.d. doses of levodopa/benserazide did not significantly aggravate orthostatic or postprandial hypotension.

Cobalamin supplementation improves cognitive and cerebral function in older, cobalamin-deficient persons.

BACKGROUND: Mild cobalamin (Cbl) deficiency is frequently found in older persons and is associated with cognitive and cerebral abnormalities. The effects of Cbl supplementation on these abnormalities are largely unknown. METHODS: In a single-blind, placebo-controlled intervention study, 16 healthy community-dwelling elderly subjects with low plasma Cbl concentration and no cognitive impairments were studied. Subjects underwent 1 month of treatment with placebo, followed by 5 months of treatment with intramuscular injections of hydroxycobalamin. Before and after measurements of plasma cobalamin, total homocysteine (tHcy), methylmalonic acid (MMA), quantitative electroencephalograph (qEEG), and psychometric tests were taken. RESULTS: After Cbl supplementation, plasma Cbl concentrations increased, and plasma MMA and tHcy concentrations decreased. The performance on the Verbal Word Learning Test, Verbal Fluency and Similarities improved. qEEG showed more fast activity and less slow activity. Lower plasma tHcy concentrations were related to increased fast activity on qEEG on the one hand and improved performance on the Verbal Word Learning Test and Similarities on the other. Increased fast or decreased slow activity on qEEG was associated with improved performance on the Verbal Word Learning Test, Similarities and Verbal Fluency. CONCLUSIONS: Electrographic signs of improved cerebral function and improved cognitive function were found after Cbl supplementation in older subjects with low plasma Cbl concentrations who were free of significant cognitive impairment. These improvements were related to a reduction of plasma tHcy concentration.

A new course in age-based medicine at the University Medical Center of Nijmegen.

In 1995 the Medical Faculty of the University Medical Center of Nijmegen revised its curriculum to be more problem-oriented and student-centered. Each of the first four years now consists of ten four-week courses constructed around specific learning objectives. For the new curriculum the authors developed a fourth-year course on age-related health problems in which selected issues of pediatrics, general practice, and geriatrics are integrated. The primary objective of this course is to enable students to understand the differences and similarities in approaches to health problems in different age groups. Moreover, by the end of the course students should be able to analyze the physical, psychological, and social aspects of age-specific medical problems and understand their consequences for prevention and treatment. The course covers age-specific health concerns (e.g., neonatal jaundice, growth problems, sudden infant death syndrome, anorexia nervosa, dementia, multiple pathology, frailty) as well as important age-related differences in pathophysiology, etiology, diagnosis, and treatment (e.g., acute abdomen, constipation, maltreatment, urinary incontinence, pharmacokinetics). Based on assessments and evaluations after the first three implementations, the authors conclude that the enthusiastically received course is an effective introduction to age-specific health problems.

Measuring the opinions of memory clinic users: patients, relatives and general practitioners.

BACKGROUND: The opinions of memory clinic users are important to assess the value of memory clinics. OBJECTIVE: To measure the quality of care of an outpatient memory clinic for the elderly as perceived by patients, their relatives and general practitioners (GPs). METHODS: An observational study was conducted to measure the opinions of the users of a typical outpatient memory clinic. Opinions on five aspects were measured: (1) communication of the results, (2) provision of diagnostic information, (3) attitude of the clinicians, (4) usefulness of the medical assessment, and (5) information and advice to relatives. Patients and relatives were both interviewed with a dementia care satisfaction questionnaire. The GPs' opinions were derived with a self-constructed questionnaire. RESULTS: On 105 consecutive assessments, 101 opinions of GPs, 81 of caregivers and 31 of patients were recorded. Positive opinions were recorded on the way the results were communicated, the usefulness of the assessment and attitude of the clinicians. In contrast to GPs and relatives, patients were less positive about the clarity of the diagnostic information received. Both relatives and GPs were negative on information and advice to relatives. CONCLUSIONS: Patients, caregivers and GPs had positive opinions about the diagnostic value of the memory clinic. Quality improvement could focus on the clarity of the diagnostic information for patients and on better advice to relatives.

Applicability of diagnostic recommendations on dementia in family practice.

OBJECTIVE: To evaluate the applicability of the Dutch dementia guideline's recommendations, including the diagnostic criteria used by family practitioners, and to explore characteristics in both patients and family practitioners which are associated with the use of these recommendations. DESIGN: An observational study was set up with a sample of 64 family practitioners who were instructed to use the Dutch national dementia guideline on incident-suspected dementia patients. The applicability was expressed as the percentage of recommendations applied. The use of diagnostic criteria was checked by comparing the family practitioners diagnoses with the diagnoses received by integrating the registered symptoms according to the DSM-III-R criteria. Associations between the number of recommendations applied, and demographic and clinical features were explored. MAIN OUTCOME MEASURES: (i) guideline applicability (ii) integrated use of DSM-III-R criteria. RESULTS: 107 patients were included. The average application rate of the guideline's 31 diagnostic key recommendations was 86% or 24.8 (SD 3.6). The family practitioners diagnoses were consistent with the expected DSM-III-R diagnoses in 26% of the cases (kappa = 0.1). A greater number of patients in a practice was positively associated with the use of recommendations. A need for referral by the family practitioners, and patients' denial of dementia were negatively associated with the use of recommendations. The presence of dementia and a patient's age were negatively associated with the use of the DSM-III-R criteria. CONCLUSIONS: The applicability of the diagnostic recommendations of the national Dutch dementia guideline in a representative sample of family practitioners was promising. Nevertheless, the diagnostic criteria of the DSM-III-R, which were part of the dementia guideline, provided little or no guidance to the family practitioners in their diagnostic decision-making. Clinical and demographic variables explained some of the variation in the use of recommendations.

Toward individualized evidence-based medicine: five "N of 1" trials of methylphenidate in geriatric patients.

OBJECTIVES: To investigate the efficacy of methylphenidate in depressed or apathetic geriatric patients. DESIGN: Five "N of 1" trials (individual cross-over, double-blinded, randomized trials). SETTING: Department of Geriatrics, University Medical Center, Nijmegen, and two nursing homes in Nijmegen, the Netherlands. PARTICIPANTS: Patients suffered from depression due to a general medical condition (n = 2); depression resistant to antidepressive drugs (n = 1), chronic apathy due to mild and moderate severe dementia (n = 2). INTERVENTION: Methylphenidate (5 mg bid) and placebo (both for two subsequent days) in 5 weeks of randomized treatment blocks. MEASUREMENTS: Montgomery Asberg Depression Rating Scale (MADRS), Apathy Evaluation Scale (AES)-clinician, the AES-informant, Barthel index and a semiquantitative checklist of adverse effects. RESULTS: Among the three depressed patients, two showed significant improvement on the MADRS (P = .089 and P = .001; alpha = 0.10), one patient's apathy showed significant improvement on AES-clinician and -informant (P = .077 and P = .086). One apathetic patient's trial was stopped because AES could not be completed. None of the patients showed significant changes in the Barthel index. No side effects developed. CONCLUSION: "N of 1" trials are useful in evaluating efficacy of methylphenidate in depressed or apathetic geriatric patients. Single-patient trials can be a useful tool in pharmacotherapeutic decision-making in frail older subjects.

[Surgery for a recently symptomatic severe carotid stenosis, indicated or not? Clinical application of 'evidence-based' medicine]. / Operatie van een recentelijk symptomatisch geworden ernstige carotisstenose of niet? 'Evidence-based' geneeskunde in de praktijk.

Two trials have shown that carotid surgery reduced the risk of stroke or death for patients with a recently symptomatic severe carotid stenosis. Nevertheless, it remains difficult to advise in individual cases. The risk of a stroke is about 20% in the next 3 years on medical treatment alone. This means that surgery is of no value in about 80% of the patients. With the help of prediction rules (developed by Rothwell and Warlow) it is possible to further individualize the decision whether or not to operate, by incorporating factors such as the angiographic roughness of the stenosis lining, the time since the cerebrovascular symptoms appeared, the extent of the stenosis, increased operation risk, sex, peripheral vascular disease and systolic blood pressure. If these prediction rules prove to be correct, doctors will be able to better advise their individual patients.