Autonomic regulation in different hypertensive phenotypes - the HELIUS study.

Background: Hypertension can be classified into different phenotypes based on systolic and diastolic blood pressure (BP) that carry a different prognosis and may therefore be differently associated with sympathetic activity. We assessed the association between cardiac autonomic function determined from continuous finger BP recordings and hypertensive phenotypes. Methods: We included 10,221 individuals aged between 18-70 years from the multi-ethnic HELIUS study. Finger BP was recorded continuously for 3-5 minutes from which cross-correlation baroreflex sensitivity (xBRS) and heart rate variability (HRV) were determined. Hypertension was classified into isolated systolic (ISH; ≥140/<90), diastolic (IDH; <140/≥90) and combined systolic and diastolic hypertension (SDH; ≥140/≥90). Differences were assessed after stratification by age (younger: ≤40, older: >40 years) and sex, using regression with correction for relevant covariates. For xBRS, values were log-transformed. Results: In younger adults with ISH, xBRS was comparable to normotensive individuals in men (ratio 0.92; 95%CI 0.84-1.01) and women (1.00; 95%CI 0.84-1.20), while xBRS was significantly lower in IDH and SDH (ratios between 0.67 and 0.80). In older adults, all hypertensive phenotypes had significantly lower xBRS compared to normotensives. We found a similar pattern for HRV in men, while in women HRV did not differ between phenotypes. Conclusions: In younger men and women ISH is not associated with a shift towards increased sympathetic control, while IDH and SDH in younger and all hypertensive phenotypes in older participants were associated with increased sympathetic control. This suggests that alterations in autonomic regulation could be a contributing factor to known prognostic disparities between hypertensive phenotypes.

Hypertension can be classified into different phenotypes based on systolic and diastolic blood pressure (BP) that carry a different prognosis. Impaired autonomic regulation is important in the pathogenesis of hypertension and independently associated with adverse cardiovascular outcomes.We analyzed 3-5 minutes continuous non-invasive finger blood pressure recordings performed in over 10.000 individuals participating in the HELIUS cohort study. From these measurements, short term heart rate variability (HRV) and cross correlation baroreflex sensitivity (xBRS) were determined using an automatic algorithm.In our analysis we observed pronounced differences in the relation between autonomic regulation and hypertensive phenotypes that depend on age and sex.Younger men and women (age 18-40 years) with isolated systolic hypertension had similar values for xBRS and HRV compared to normotensives, while isolated diastolic hypertension was associated with a shift towards increased sympathetic control. In contrast to our findings in younger individuals, all hypertensive phenotypes were associated with increased sympathetic control in older participants (age 40-70 years).This supports earlier studies showing prognostic differences and suggests that alterations in sympathovagal balance could be a contributing factor to the disparities between phenotypes.

The course of post-stroke apathy in relation to cognitive functioning: a prospective longitudinal cohort study.

Apathy is common after stroke and has been associated with cognitive impairment. However, causality between post-stroke apathy and cognitive impairment remains unclear. We assessed the course of apathy in relation to changes in cognitive functioning in stroke survivors. Using the Apathy Scale (AS) and cognitive tests on memory, processing speed and executive functioning at six- and 15 months post-stroke we tested for associations between (1) AS-scores and (change in) cognitive scores; (2) apathy course (persistent/incident/resolved) and cognitive change scores. Of 117 included participants, 29% had persistent apathy, 13% apathy resolving over time and 10% apathy emerging between 6-15 months post-stroke. Higher AS-scores were cross-sectionally and longitudinally associated with lower cognitive scores. Relations between apathy and cognitive change scores were ambiguous. These inconsistent relations between apathy and changes in cognition over time suggest that post-stroke apathy does not directly impact cognitive performance. Both these sequelae of stroke require separate attention.

Evaluation of the Marburg Heart Score and INTERCHEST score compared to current telephone triage for chest pain in out-of-hours primary care.

INTRODUCTION: Chest pain is a common and challenging symptom for telephone triage in urgent primary care. Existing chest-pain-specific risk scores originally developed for diagnostic purposes may outperform current telephone triage protocols. METHODS: This study involved a retrospective, observational cohort of consecutive patients evaluated for chest pain at a large-scale out-of-hours primary care facility in the Netherlands. We evaluated the performance of the Marburg Heart Score (MHS) and INTERCHEST score as stand-alone triage tools and compared them with the current decision support tool, the Netherlands Triage Standard (NTS). The outcomes of interest were: C­statistics, calibration and diagnostic accuracy for optimised thresholds with major events as the reference standard. Major events are a composite of all-cause mortality and both cardiovascular and non-cardiovascular urgent underlying conditions occurring within 6 weeks of initial contact. RESULTS: We included 1433 patients, 57.6% women, with a median age of 55.0 years. Major events occurred in 16.4% (n = 235), of which acute coronary syndrome accounted for 6.8% (n = 98). For predicting major events, C­statistics for the MHS and INTERCHEST score were 0.74 (95% confidence interval: 0.70-0.77) and 0.76 (0.73-0.80), respectively. In comparison, the NTS had a C-statistic of 0.66 (0.62-0.69). All had appropriate calibration. Both scores (at threshold ≥ 2) reduced the number of referrals (with lower false-positive rates) and maintained equal safety compared with the NTS. CONCLUSION: Diagnostic risk stratification scores for chest pain may also improve telephone triage for major events in out-of-hours primary care, by reducing the number of unnecessary referrals without compromising triage safety. Further validation is warranted.

Is early menopause a potential criterion for cardiovascular risk screening to detect high risk in a multi-ethnic population? The Helius study.

BACKGROUND: Women at risk of cardiovascular disease (CVD) may be missed with current eligibility criteria for CVD risk screening, particularly those from ethnic minority groups, among whom high risk is prevalent at a younger age. Early menopause (EM; menopause before 45 years) is associated with increased risk of CVD, and may be a potential eligibility criterion for CVD risk screening. AIMS AND OBJECTIVES: To determine the contribution of EM to current criteria from patient history (having a family history of CVD, current smoking, obesity and age over 50 years) for identifying women eligible for CVD risk screening in a multi-ethnic population. METHODS AND RESULTS: We used baseline data (2011-2015) from 4512 women aged 45-70 years of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan ethnic origin from the HELIUS study (Amsterdam, Netherlands). Models based on current eligibility criteria with and without EM were compared on area under the curve (AUC) with regard to estimated 10-year CVD risk using the Dutch SCORE. Overall, models with EM had a higher AUC, but changes were not statistically significant. In our total sample of women aged between 45 and 70 years, the AUC changed from 0.70 (95%CI 0.69-0.72) to 0.71 (95%CI 0.69-0.72). Among women aged 45-50 years the AUC changed from 0.66 (95%CI 0.58-0.74) to 0.68 (95%CI 0.59-0.74). Results were consistent across ethnic groups. CONCLUSIONS: The addition of EM to current eligibility criteria did not improve the detection of women at high CVD risk in a multi-ethnic sample of women aged 45-70 years.

Differences in the prevalence of intermediate hyperglycaemia and the associated incidence of type 2 diabetes mellitus by ethnicity: The HELIUS study.

AIMS: We aimed to describe differences in the prevalence of intermediate hyperglycaemia (IH) between six ethnic groups. Moreover, to investigate differences in the association of the classifications of IH with the incidence of T2DM between ethnic groups. METHODS: We included 3759 Dutch, 2826 African Surinamese, 1646 Ghanaian, 2571 Turkish, 2691 Moroccan and 1970 South Asian Surinamese origin participants of the HELIUS study. IH was measured by fasting plasma glucose (FPG) and HbA1c. We calculated age-, BMI and physical-activity-adjusted prevalence of IH by sex, and calculated age and sex-adjusted hazard ratios (HR)for the association between IH and T2DM in each ethnic group. RESULTS: The prevalence of IH was higher among ethnic minority groups (68.6-41.7%) than the Dutch majority (34.9%). The prevalence of IH categories varied across subgroups. Combined increased FPG and HbA1c was most prevalent in South-Asian Surinamese men (27.6%, 95 %CI: 24.5-30.9%), and in Dutch women (4.2%, 95 %CI: 3.4-5.1%). The HRs for T2DM for each IH-classification did not differ significantly between ethnic groups. HRs were highest for the combined classification, e.g., HR = 8.1, 95 %CI: 2.5-26.6 in the Dutch. CONCLUSION: We found a higher prevalence of IH in ethnic minority versus majority groups, but did not find evidence for a differential association of IH with incident T2DM.

GPs' views on the implementation of combined lifestyle interventions in primary care in the Netherlands: a qualitative study.

OBJECTIVES: Prevention and lifestyle support are emerging topics in general practice. Healthcare insurance companies reimburse combined lifestyle interventions (CLIs) in the Netherlands since January 2019. CLIs support people with overweight (body mass index, BMI 25-30) or obesity (BMI >30) to reduce weight in peer groups. General practitioners (GPs) are key in the successful implementation of lifestyle interventions in primary care. This study explored GPs' experiences and views on the implementation of CLIs to identify barriers and facilitators to the successful implementation in primary care. DESIGN: Qualitative study using semistructured interviews. Content analysis consisted of thematic coding and mapping a first stage of predefined and second stage of iterative evolving set of themes. SETTING: GPs were interviewed in a variety of primary care practices between February and April 2019. PARTICIPANTS: Fifteen GPs were purposively recruited for semi-structured interviews through snowballing. RESULTS: Experiences with lifestyle support among GPs ranged from referring patients to other healthcare professionals to taking a proactive role in lifestyle support themselves. Whether or not GPs took an active role in lifestyle support was related to their belief in the effect of lifestyle interventions. Overall, GPs had little experience with CLI in every day practice. Perceived barriers were a lack of availability of CLIs in the region and the potential lack of added value of CLIs on top of existing lifestyle support. Perceived facilitators were coordination of care provision by GP cooperatives and monitoring of the CLI implementation and their results. Reimbursement of CLIs without any costs for participants enabled application. CONCLUSION: The importance of lifestyle interventions in primary care was acknowledged by all GPs, but they differed in their level of experience with providing lifestyle support and awareness of CLIs. Successful integration of CLIs with primary care requires a solid promotion, a well-coordinated implementation strategy and structural evaluation of long-term effectiveness.

The Effect of Multidomain Interventions on Global Cognition, Symptoms of Depression and Apathy - A Pooled Analysis of Two Randomized Controlled Trials.

BACKGROUND: Cardiovascular risk factors and lifestyle factors are associated with an increased risk of cognitive decline and dementia in observational studies, and have been targeted by multidomain interventions. OBJECTIVES: We pooled individual participant data from two multi-domain intervention trials on cognitive function and symptoms of depression to increase power and facilitate subgroup analyses. DESIGN: Pooled analysis of individual participant data. SETTING: Prevention of Dementia by Intensive Vascular Care trial (preDIVA) and Multidomain Alzheimer Preventive Trial (MAPT). PARTICIPANTS: Community-dwelling individuals, free from dementia at baseline. INTERVENTION: Multidomain interventions focused on cardiovascular and lifestyle related risk factors. MEASUREMENTS: Data on cognitive functioning, depressive symptoms and apathy were collected at baseline, 2 years and 3-4 years of follow-up as available per study. We analyzed crude scores with linear mixed models for overall cognitive function (Mini Mental State Examination [MMSE]), and symptoms of depression and apathy (15-item Geriatric Depression Scale). Prespecified subgroup analyses were performed for sex, educational level, baseline MMSE <26, history of hypertension, and history of stroke, myocardial infarction and/or diabetes mellitus. RESULTS: We included 4162 individuals (median age 74 years, IQR 72, 76) with a median follow-up duration of 3.7 years (IQR 3.0 to 4.1 years). No differences between intervention and control groups were observed on change in cognitive functioning scores and symptoms of depression and apathy scores in the pooled study population. The MMSE declined less in the intervention groups in those with MMSE <26 at baseline (N=250; MD: 0.84; 95%CI: 0.15 to 1.54; p<0.001). CONCLUSIONS: We found no conclusive evidence that multidomain interventions reduce the risk of global cognitive decline, symptoms of depression or apathy in a mixed older population. Our results suggest that these interventions may be more effective in those with lower baseline cognitive functioning. Extended follow-up for dementia occurrence is important to inform on the potential long-term effects of multidomain interventions.

[Practice variation in diagnostic testing for dementia; a nation-wide overview]. / Praktijkvariatie in aanvullend onderzoek bij dementie.

OBJECTIVE: To determine variation in diagnostic strategies for diagnosing dementia between Dutch hospitals. DESIGN: Descriptive, retrospective research based on claim data of Dutch health insurers. METHOD: Information on the use of diagnostic ancillary services carried out from 2015 to 2018 was collected via national-level insurance claims for patients who received a (new) diagnose-coding for dementia in 2018. Hospitals were included in the analysis if they diagnosed >50 patients with dementia. We distinguished academic medical centres (AMC), non-academic training hospitals (TH) and general hospitals (GH). RESULTS: In 2018, 20.073 new cases of dementia were diagnosed in 71 hospitals. The percentages of patients undergoing MRI/CT-imaging ranged from 37 to 99% (median 76.7%), neuropsychological-assessment from 0-89% (median 31.8%), cerebrospinal fluid examination from 0-14% (median 2.4%), PET/SPECT-imaging from 0-16% (median 6.2%) and electroencephalography from 1-20% (median 5.8%). Practice variation was comparable in AMCs, THs and GHs and was evidently skewed for PET/SPECT-imaging, electroencephalography and cerebrospinal fluid examination. There were no distinct differences according to case-mix characteristics or hospital volume. The percentage of patients subjected to ancillary diagnostic investigations decreased sharply with increasing age. CONCLUSION: In the Netherlands, diagnostic ancillary methods used vary widely between hospitals both in frequency and modality. This variation may be driven by limited evidence of diagnostic accuracy and added value of different diagnostic tests, variations in doctor and patient preferences and differences in available diagnostic techniques per hospital. Further exploration of this heterogeneity may help to identify a strategy that combines the most benefit with the least burden.

Predictive value of traditional risk factors for cardiovascular disease in older people: A systematic review.

With increasing age, associations between traditional risk factors (TRFs) and cardiovascular disease (CVD) shift. It is unknown which mid-life risk factors remain relevant predictors for CVD in older people. We systematically searched PubMed and EMBASE on August 16th 2019 for studies assessing predictive ability of >1 of fourteen TRFs for fatal and non-fatal CVD, in the general population aged 60+. We included 12 studies, comprising 11 unique cohorts. TRF were evaluated in 2 to 11 cohorts, and retained in 0-70% of the cohorts: age (70%), diabetes (64%), male sex (57%), systolic blood pressure (SBP) (50%), smoking (36%), high-density lipoprotein cholesterol (HDL) (33%), left ventricular hypertrophy (LVH) (33%), total cholesterol (22%), diastolic blood pressure (20%), antihypertensive medication use (AHM) (20%), body mass index (BMI) (0%), hypertension (0%), low-density lipoprotein cholesterol (0%). In studies with low to moderate risk of bias, systolic blood pressure (SBP) (80%), smoking (80%) and HDL cholesterol (60%) were more often retained. Model performance was moderate with C-statistics ranging from 0.61 to 0.77. Compared to middle-aged adults, in people aged 60+ different risk factors predict CVD and current prediction models perform only moderate at best. According to most studies, age, sex and diabetes seem valuable predictors of CVD in old-age. SBP, HDL cholesterol and smoking may also have predictive value. Other blood pressure and cholesterol related variables, BMI, and LVH seem of very limited or no additional value. Without competing risk analysis, predictors are overestimated.

[Diagnostics in memory loss: for whom, what and when?] / Diagnostiek bij geheugenklachten.

With the advancement of diagnostic tests, the call for an ever-earlier diagnosis of people with memory problems is becoming louder. Diagnostic tests for people with mild cognitive impairment are in fact prognostic tests, complicating the application and interpretation of test results. There is currently insufficient evidence on the incremental diagnostic (or prognostic) value of specific diagnostic tests including MRI, CSF and PET scanning in representative memory clinic populations. Labelling large groups of people who may never develop dementia as having prodromal Alzheimer's disease may be more harmful than a postponed nosological diagnosis in those with mild cognitive impairment. The current Dutch practice guideline on dementia, with a reticent attitude towards the use of diagnostic tests in patients with cognitive impairment, is appropriate and scientifically sound.

[Is dementia preventable through intensive vascular care? The preDIVA trial]. / Is dementie te voorkomen door intensieve vaatzorg?

OBJECTIVE: To assess whether intensive vascular care in GP practices can prevent dementia in a population of community-dwelling older people. METHOD: This pragmatic cluster-randomised open-label study (ISRCTN29711771) was conducted in persons aged 70-78 years who were registered with Dutch GP practices. The only exclusion criteria were a diagnosis of dementia and limited life expectancy. Practices were randomly assigned to an intervention arm or a control arm. Participants in the interventional arm underwent a cardiovascular check-up every 4 months for six years by a practice nurse. Primary outcomes were cumulative incidence of dementia and functional limitations. Main secondary outcomes were the incidence of cardiovascular disease and mortality. RESULTS: Between June 2006 and March 2009, 116 GP practices (3526 participants) were recruited and randomly assigned: 63 (1890 participants) to the intervention group and 53 (1636 participants) to the control group. Primary outcome data were obtained for 3454 (98%) participants; median follow-up was 6.7 years. In this period, dementia was diagnosed in 121/1853 (6.5%) participants in the intervention group and in 112/1601 (7.0%) participants in the control group. This difference was not significant (hazard ratio 0.92, 95% CI 0.71-1.19). No differences were found with regard to functional decline, incident cardiovascular disease and mortality. CONCLUSION: Long-term intensive vascular care for community-dwelling elderly patients, provided in a primary care setting, does not result in a reduced incidence of dementia, functional limitations or mortality. There is, however, possibly an effect in elderly patients with untreated or sub-optimally treated hypertension; this warrants further research.

Minimal Important Change and Minimal Detectable Change in Activities of Daily Living in Community-Living Older People.

OBJECTIVE: To estimate the minimal important change (MIC) and the minimal detectable change (MDC) of the Katz-activities of daily living (ADL) index score and the Lawton instrumental activities of daily living (IADL) scale. DESIGN: Data from a cluster-randomized clinical trial and a cohort study. SETTING: General practices in the Netherlands. PARTICIPANTS: 3184 trial participants and 51 participants of the cohort study with a mean age of 80.1 (SD 6.4) years. MEASUREMENTS: At baseline and after 6 months, the Katz-ADL index score (0-6 points), the Lawton IADL scale (0-7 points), and self-perceived decline in (I)ADL were assessed using a self-reporting questionnaire. MIC was assessed using anchor-based methods: the (relative) mean change score; and using distributional methods: the effect size (ES), the standard error of measurement (SEM), and 0.5 SD. The MDC was estimated using SEM, based on a test-retest study (2-week interval) and on the anchor-based method. RESULTS: Anchor-based MICs of the Katz-ADL index score were 0.47 points, while distributional MICs ranged from 0.18 to 0.47 points. Similarly, anchor-based MICs of the Lawton IADL scale were between 0.31 and 0.54 points and distributional MICs ranged from 0.31 to 0.77 points. The MDC varies by sample size. For the MIC to exceed the MDC at least 482 patients are needed. CONCLUSION: The MIC of both the Katz-ADL index and the Lawton IADL scale lie around half a point. The certainty of this conclusion is reduced by the variation across calculational methods.

[Web-based interventions targeting cardiovascular risk factors in older people; a systematic review and meta-analysis]. / Internetinterventies voor cardiovasculaire risicofactoren bij ouderen.

OBJECTIVE: To evaluate whether web-based interventions for cardiovascular risk factor management reduce the risk of cardiovascular disease in older people. DESIGN: Systematic review and meta-analysis. METHOD: Embase, Medline, Cochrane Library and CINAHL were systematically searched from January 1995 to 3 November 2014. We included all randomised controlled trials for web-based interventions targeting cardiovascular risk factors in populations with a mean age of 50 and older. The outcome measures were cardiovascular risk factors (blood pressure, HbA1c, LDL cholesterol, weight, smoking status and physical activity) and the incidence of cardiovascular disease. We used random-effects models to pool the results of the studies. RESULTS: A total of 57 studies (19,862 participants) fulfilled eligibility criteria, and 47 of these were suitable for meta-analysis. We found a significant reduction in systolic blood pressure (-2.66 mmHg, 95% CI -3.81 to -1.52), diastolic blood pressure (-1.26 mmHg, 95% CI -1.92 to -0.60), HbA1c level (-0.13%, 95% CI -0.22 to -0.05), LDL cholesterol level (-0.06 mmol/l, 95% CI -0.10 to -0.01), weight (-1.34 kg, 95% CI -1.91 to -0.77), and an increase in physical activity (standardized mean difference 0.25, 95% CI 0.10-0.39) in the intervention group when compared with the control group. Treatment effects were more pronounced in studies of short duration (< 12 months) and when combining the web-based intervention with human support by a health care professional. No difference in the incidence of cardiovascular disease was found between groups. CONCLUSION: Web-based interventions have a beneficial effect on the cardiovascular risk profile, but this effect is modest and declines with time. Currently, there is insufficient evidence that this can prevent cardiovascular disease. A focus on long-term effects, effect-sustainability and clinical endpoints is recommended for future studies.

Assessment of the quality of fall detection and management in primary care in the Netherlands based on the ACOVE quality indicators.

UNLABELLED: We determined adherence to nine fall-related ACOVE quality indicators to investigate the quality of management of falls in the elderly population by general practitioners in the Netherlands. Our findings demonstrate overall low adherence to these indicators, possibly indicating insufficiency in the quality of fall management. Most indicators showed a positive association between increased risk for functional decline and adherence, four of which with statistical significance. INTRODUCTION: This study aims to investigate the quality of detection and management of falls in the elderly population by general practitioners in the Netherlands, using the Assessing Care of Vulnerable Elders (ACOVE) quality indicators. METHODS: Community-dwelling persons aged 70 years or above, registered in participating general practices, were asked to fill in a questionnaire designed to determine general practitioner (GP) adherence to fall-related indicators. We used logistic regression to estimate the association between increased risk for functional decline-quantified by the Identification of Seniors At Risk for Primary Care score-and adherence. We then cross-validated the self-reported falls with medical records. RESULTS: Of the 950 elders responding to our questionnaire, only 10.6 % reported that their GP proactively asked them about falls. Of the 160 patients who reported two or more falls, or one fall for which they visited the GP, only 23.1 % had fall documentation in their records. Adherence ranged between 13.6 and 48.6 %. There was a significant positive association between the ISAR-PC scores and adherence in four QIs. Documentation of falls was highest (36.7 %) in patients whom the GP had proactively asked about falls. CONCLUSION: Based on patient self-reports, adherence to the ACOVE fall-related indicators was poor, suggesting that the quality of evaluation and management of falls in community-dwelling older persons in the Netherlands is poor. The documentation of falls and fall-related risk factors was also poor. However, for most QIs, adherence to them increased with the increase in the risk of functional decline.

Validation of the Care-Related Quality of Life Instrument in different study settings: findings from The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS).

PURPOSE: Validity is a contextual aspect of a scale which may differ across sample populations and study protocols. The objective of our study was to validate the Care-Related Quality of Life Instrument (CarerQol) across two different study design features, sampling framework (general population vs. different care settings) and survey mode (interview vs. written questionnaire). METHODS: Data were extracted from The Older Persons and Informal Caregivers Minimum DataSet (TOPICS-MDS, www.topics-mds.eu ), a pooled public-access data set with information on >3,000 informal caregivers throughout the Netherlands. Meta-correlations and linear mixed models between the CarerQol's seven dimensions (CarerQol-7D) and caregiver's level of happiness (CarerQol-VAS) and self-rated burden (SRB) were performed. RESULTS: The CarerQol-7D dimensions were correlated to the CarerQol-VAS and SRB in the pooled data set and the subgroups. The strength of correlations between CarerQol-7D dimensions and SRB was weaker among caregivers who were interviewed versus those who completed a written questionnaire. The directionality of associations between the CarerQol-VAS, SRB and the CarerQol-7D dimensions in the multivariate model supported the construct validity of the CarerQol in the pooled population. Significant interaction terms were observed in several dimensions of the CarerQol-7D across sampling frame and survey mode, suggesting meaningful differences in reporting levels. CONCLUSIONS: Although good scientific practice emphasises the importance of re-evaluating instrument properties in individual research studies, our findings support the validity and applicability of the CarerQol instrument in a variety of settings. Due to minor differential reporting, pooling CarerQol data collected using mixed administration modes should be interpreted with caution; for TOPICS-MDS, meta-analytic techniques may be warranted.

[Comparing case management care models for people with dementia and their caregivers: the design of the COMPAS study]. / Implementatie, effecten en kosten van casemanagement voor mensen met dementie en hun mantelzorgers: beschrijving van de COMPAS studie.

BACKGROUND: Dementia care in The Netherlands is shifting from fragmented, ad hoc care to more coordinated and personalized care. Case management contributes to this shift. The linkage model and a combination of intensive case management and joint agency care models were selected based on their emerging prominence in The Netherlands. It is unclear if these different forms of case management are more effective than usual care in improving or preserving the functioning and well-being at the patient and caregiver level and at the societal cost. OBJECTIVE: The objective of this article is to describe the design of a study comparing these two case management care models against usual care. Clinical and cost outcomes are investigated while care processes and the facilitators and barriers for implementation of these models are considered. DESIGN: Mixed methods include a prospective, observational, controlled, cohort study among persons with dementia and their primary informal caregiver in regions of The Netherlands with and without case management including a qualitative process evaluation. Community-dwelling individuals with a dementia diagnosis with an informal caregiver are included. The primary outcome measure is the Neuropsychiatric Inventory for the people with dementia and the General Health Questionnaire for their caregivers. Costs are measured from a societal perspective. Semi-structured interviews with stakeholders based on the theoretical model of adaptive implementation are planned. RESULTS: 521 pairs of persons with dementia and their primary informal caregiver were included and are followed over two years. In the linked model substantially more impeding factors for implementation were identified compared with the model. DISCUSSION: This article describes the design of an evaluation study of two case management models along with clinical and economic data from persons with dementia and caregivers. The impeding and facilitating factors differed substantially between the two models. Further results on cost-effectiveness are expected by the beginning of 2015. This is a Dutch adaptation of MacNeil Vroomen et al., Comparing Dutch case management care models for people with dementia and their caregivers: The design of the COMPAS study.

Symptoms of apathy are associated with progression from mild cognitive impairment to Alzheimer's disease in non-depressed subjects.

BACKGROUND: Apathy is a common symptom in various neuropsychiatric diseases including mild cognitive impairment (MCI) and dementia. Apathy may be associated with an increased risk of cognitive decline. The objective of this study was to investigate if apathy predicts the progression from MCI to Alzheimer's disease (AD). METHODS: The Alzheimer's Disease Neuroimaging Initiative is a prospective multicentre cohort study. At baseline, 397 patients with MCI without major depression were included. Clinical data and the Geriatric Depression Scale at baseline were used. Apathy was defined based on the 3 apathy items of the 15-item Geriatric Depression Scale. The main outcome measure was the association of apathy with progression from MCI to AD. RESULTS: During an average follow-up of 2.7 years (SD 1.0), 166 (41.8%) patients progressed to AD. The presence of symptoms of apathy without symptoms of depressive affect increased the risk of progression from MCI to AD (hazard ratio = 1.85, 95% CI = 1.09-3.15). Apathy in the context of symptoms of depressive affect or symptoms of depressive affect alone, without apathy, did not increase the risk of progression to AD. CONCLUSIONS: Symptoms of apathy, but not symptoms of depressive affect, increase the risk of progression from MCI to AD. Apathy in the context of symptoms of depressive affect does not increase this risk. Symptoms of apathy and depression have differential effects on cognitive decline.

Vascular risk factors and dementia--towards prevention strategies.

Several cohort studies have shown that vascular risk factors including hypertension, hypercholesterolaemia, diabetes mellitus, smoking, obesity and lack of physical exercise in midlife and to a lesser extent in late life, are associated with an increased risk of dementia. The results from randomised controlled clinical trials on treatment of these risk factors are not conclusive for the effect on cognitive decline and dementia. Studies investigating the effect of a multi-component intervention aimed at vascular risk factors to prevent or slow down cognitive decline and dementia will hopefully give the answer as to whether such an intervention is efficacious. This requires large clinical trials in an elderly population with long follow-up and several competing risks, making it difficult from an organisational and methodological point of view. Major challenges for future studies are to select the optimal population, set the optimal treatment targets and select clinically relevant outcome parameters.

Methodological issues in a cluster-randomized trial to prevent dementia by intensive vascular care.

OBJECTIVES: Description of methodological issues in a trial designed to evaluate if a multi-component intervention aimed at vascular risk factors can prevent dementia. DESIGN, SETTING AND PARTICIPANTS: Multi-center, open, cluster-randomized controlled clinical trial (preDIVA) including 3535 non-demented subjects aged 70-78, executed in primary practice and coordinated from one academic hospital. General practices are randomized to standard care or intensive vascular care. INTERVENTION: Vascular care consists of 4-monthly visits to a practice nurse who monitors all cardiovascular risk factors. Hypertension, hypercholesterolemia, overweight, lack of physical exercise and diabetes are strictly controlled according to a protocol and treated in a way, tailored to the characteristics of individual participants. MEASUREMENTS: Primary outcomes are incident dementia and disability; secondary outcomes are mortality, vascular events (stroke, myocardial infarction, peripheral vascular disease), cognitive decline and depression. RESULTS: Between May 2006 and February 2009, 3535 subjects from 115 general practices have been included. The clusters have an average size of 31 (SD 22, range 2-114). 1658 Patients from 52 practices were randomized to the standard care condition and 1877 patients in 63 practices to the vascular care condition. DISCUSSION: When designing a cluster-randomized trial, clustering of patient data within GP practices leads to a loss of power. This should be adjusted for in the power calculation. Since intensive vascular care will probably lead to a reduction in cardiovascular mortality, the competing risks of mortality and dementia should be taken into account.