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Objectives: To evaluate the effect of a practice-based, culturally appropriate patient education intervention on blood pressure (BP) and treatment adherence among patients of African origin with uncontrolled hypertension., Methods: Cluster randomised trial involving four Dutch primary care centres and 146 patients (intervention n=75, control n=71), who met the following inclusion criteria: self-identified Surinamese or Ghanaian; ≥ 20 years; treated for hypertension; SBP ≥ 140 mmHg. All patients received usual hypertension care. The intervention-group was also offered three nurse-led, culturally appropriate hypertension education sessions. BP was assessed with Omron 705-IT and treatment adherence with lifestyle- and medication adherence scales., Results: 139 patients (95%) completed the study (intervention n=71, control n=68). Baseline characteristics were largely similar for both groups. At six months, we observed a SBP reduction of ≥ 10 mmHg -primary outcome- in 48% of the intervention group and 43% of the control group. When adjusted for pre-specified covariates age, sex, hypertension duration, education, baseline measurement and clustering effect, the between-group difference was not significant (OR; 0.42; 95% CI: 0.11 to 1.54; P=0.19). At six months, the mean SBP/DBD had dropped by 10/5.7 (SD 14.3/9.2)mmHg in the intervention group and by 6.3/1.7 (SD 13.4/8.6)mmHg in the control group. After adjustment, between-group differences in SBP and DBP reduction were -1.69 mmHg (95% CI: -6.01 to 2.62, P=0.44) and -3.01 mmHg (-5.73 to -0.30, P=0.03) in favour of the intervention group. Mean scores for adherence to lifestyle recommendations increased in the intervention group, but decreased in the control group. Mean medication adherence scores improved slightly in both groups. After adjustment, the between-group difference for adherence to lifestyle recommendations was 0.34 (0.12 to 0.55; P=0.003). For medication adherence it was -0.09 (-0.65 to 0.46; P=0.74)., Conclusion: This intervention led to significant improvements in DBP and adherence to lifestyle recommendations, supporting the need for culturally appropriate hypertension care., Trial Registration: Controlled-Trials.com ISRCTN35675524.

Objectives: To investigate the 6-month functional prognosis of dizziness in older adults in primary care, to identify important predictors of dizziness-related impairment, and to construct a score to assist risk prediction., Design: Prospective cohort study with 6-month follow-up., Setting: Twenty-four primary care practices in the Netherlands., Participants: Four hundred seventeen older adults (mean age 78.5, range 65-95, 74% female) presenting consecutively to primary care with dizziness., Measurements: Tests, including history and physical and additional examination, previously selected by an international expert panel and based on an earlier systematic review, were performed. The main outcome measure was 6-month dizziness-related impairment score measured using the Dizziness Handicap Inventory., Results: Follow-up was complete for 92% of participants. Although 61% of participants experienced less impairment at 6 months, 130 participants (34%) showed persistent dizziness-related impairment. Factors most predictive of dizziness-related impairment at 6 months were onset of dizziness at least 6 months before inclusion, standing still as a dizziness-provoking circumstance, trouble with walking or (almost) falling (associated symptom), polypharmacy, absence of diabetes mellitus, presence of anxiety or depressive disorder, and impaired functional mobility. A score was constructed using these predictors to estimate the functional prognosis of dizziness at 6 months., Conclusion: A score based on the presence of easily obtainable clinical information facilitates identification of older adults in primary care with poor functional prognosis of their dizziness without exactly knowing the cause(s) of their dizziness. Clinical management might be most effective by treating factors that can be influenced, such as polypharmacy, anxiety and depression, and functional mobility., (© 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.)

Context: Apathy in community-dwelling elderly individuals has been associated with a history of stroke and other cardiovascular disease., Objective: To assess the relationship between symptoms of apathy and cardiovascular risk factors or disease (stroke or other) in a large sample of elderly people aged 70 to 78 years without depression or dementia., Design: Cross-sectional data analysis within an ongoing cluster-randomized, open, multicenter trial., Setting: The Netherlands, general community., Participants: We studied 3534 elderly individuals without dementia who were included in the Prevention of Dementia by Intensive Vascular Care trial., Main Outcome Measures: Symptoms of apathy, assessed with 3 items from the 15-item Geriatric Depression Scale, in participants with few or no depressive symptoms., Results: The median age of participants was 74.3 years. Principal components analysis of the Geriatric Depression Scale confirmed a separate factor for the apathy items (Geriatric Depression Scale-3A). Two or more symptoms of apathy were present in 699 participants (19.9%), of whom 372 (53.2%) were without depressive symptoms (Geriatric Depression Scale-12D score <2). Ordinal regression analysis showed that increasing apathy in the absence of depressive symptoms was associated with a history of stroke (odds ratio, 1.79; 95% CI, 1.38-2.31) and cardiovascular disease other than stroke (1.28; 1.09-1.52). Exploratory analysis among 1889 participants free from stroke and other cardiovascular disease revealed an association between apathy score and the following cardiovascular risk factors: systolic blood pressure (P = .03), body mass index (P = .002), type 2 diabetes mellitus (P = .07), and C-reactive protein (P < .001)., Conclusions: Symptoms indicative of apathy are common in community-dwelling nondemented older people who are free from depression. The independent association of stroke, other cardiovascular disease, and cardiovascular risk factors with symptoms of apathy suggests a causal role of vascular factors.

Background: Physical activity (PA) is important in older adults for the maintenance of functional ability. Assessing PA may be difficult. Few PA questionnaires have been compared to activity monitors. We examined reproducibility and validity of the self-administered Longitudinal Ageing Study Amsterdam Physical Activity Questionnaire (LAPAQ) against a triaxial accelerometer (ACTR) (Sensewear(®) Pro) in older adults., Methods: Participants wore the ACTR continuously for two weeks. After 2 (T [time] = 1) and 4 (T = 2) weeks, participants completed the LAPAQ. Since the LAPAQ asks about 2 weeks' worth of physical activity, the ACTR and LAPAQ coincided at T1. T2 was used to assess the reproducibility of the LAPAQ results only. We calculated Pearson's correlation coefficients (PCC) to examine reproducibility and validity. For visualization, we used scatterplots and Bland-Altman plots. With a receiver operating characteristics (ROC) curve we assessed how well the LAPAQ identifies older adults whose activity level is below official recommendations., Results: A total of 89 persons were included. Of the participants, 48% were men; median age was 73, and median body mass index was 25. The 2-week mean total duration of activity was 2788 (ACTR, T = 1), 2439 (LAPAQ T = 1), and 1994 (LAPAQ T = 2) minutes. As a reference, 2 full weeks contained 20,160 minutes. Reproducibility of the LAPAQ was moderate (PCC 0.68, 95% CI 0.55-0.80). The median difference between LAPAQ at T = 1 and the ACTR (LAPAQ minus ACTR) was -510 minutes and the PCC was 0.25 (95% CI 0.07-0.44). The area under the ROC curve was 0.73 (95% CI 0.59-0.86)., Conclusion: LAPAQ underestimates PA and seems unsuitable for exact measurement in older adults. However, it may be used to determine if a person's PA level is below the recommended level.

Background: Dizziness is a common and often disabling symptom, but diagnosis often remains unclear; especially in older persons where dizziness tends to be multicausal. Research on dizziness-related impairment might provide options for a functional oriented approach, with less focus on finding diagnoses. We therefore studied dizziness-related impairment in older primary care patients and aimed to identify indicators related to this impairment., Methods: In a cross-sectional study we included 417 consecutive patients of 65 years and older presenting with dizziness to 45 general practitioners in the Netherlands from July 2006 to January 2008. We performed tests, including patient history, and physical and additional examination, previously selected by an international expert panel and based on an earlier systematic review. Our primary outcome was impact of dizziness on everyday life measured with the Dutch validated version of the Dizziness Handicap Inventory (DHI). After a bootstrap procedure (1500x) we investigated predictability of DHI-scores with stepwise backward multiple linear and logistic regressions., Results: DHI-scores varied from 0 to 88 (maximum score: 100) and 60% of patients experienced moderate or severe impact on everyday life due to dizziness. Indicators for dizziness-related impairment were: onset of dizziness 6 months ago or more (OR 2.8, 95% CI 1.7-4.7), frequency of dizziness at least daily (OR 3.3, 95% CI 2.0-5.4), duration of dizziness episode one minute or less (OR 2.4, 95% CI 1.5-3.9), presence of anxiety and/or depressive disorder (OR 4.4, 95% CI 2.2-8.8), use of sedative drugs (OR 2.3, 95% CI 1.3-3.8) , and impaired functional mobility (OR 2.6, 95% CI 1.7-4.2). For this model with only 6 indicators the AUC was .80 (95% CI .76-.84)., Conclusions: Dizziness-related impairment in older primary care patients is considerable (60%). With six simple indicators it is possible to identify which patients suffer the most from their dizziness without exactly knowing the cause(s) of their dizziness. Influencing these indicators, if possible, may lead to functional improvement and this might be effective in patients with moderate or severe impact of dizziness on their daily lives.

Attention-Deficit/Hyperactivity Disorder (ADHD) shares a genetic basis with motor coordination problems and probably motor timing problems. In line with this, comparable problems in motor timing should be observed in first degree relatives and might, therefore, form a suitable endophenotypic candidate. This hypothesis was investigated in 238 ADHD-families (545 children) and 147 control-families (271 children). A motor timing task was administered, in which children had to produce a 1,000 ms interval. In addition to this task, two basic motor tasks were administered to examine speed and variability of motor output, when no timing component was required. Results indicated that variability in motor timing is a useful endophenotypic candidate: It was clearly associated with ADHD, it was also present in non-affected siblings, and it correlated within families. Accuracy (under- versus over-production) in motor timing appeared less useful: Even though accuracy was associated with ADHD (probands and affected siblings had a tendency to under-produce the 1,000 ms interval compared to controls), non-affected siblings did not differ from controls and sibling correlations were only marginally significant. Slow and variable motor output without timing component also appears present in ADHD, but not in non-affected siblings, suggesting these deficits not to be related to a familial vulnerability for ADHD. Deficits in motor timing could not be explained by deficits already present in basic motor output without a timing component. This suggests abnormalities in motor timing were predominantly related to deficient motor timing processes and not to general deficient motor functioning. The finding that deficits in motor timing run in ADHD-families suggests this to be a fruitful domain for further exploration in relation to the genetic underpinnings of ADHD.

Maximum likelihood estimation techniques are widely used in twin and family studies, but soon reach computational boundaries when applied to highly complex models (e.g., models including gene-by-environment interaction and gene-environment correlation, item response theory measurement models, repeated measures, longitudinal structures, extended pedigrees). Markov Chain Monte Carlo (MCMC) algorithms are very well suited to fit complex models with hierarchically structured data. This article introduces the key concepts of Bayesian inference and MCMC parameter estimation and provides a number of scripts describing relatively simple models to be estimated by the freely obtainable BUGS software. In addition, inference using BUGS is illustrated using a data set on follicle-stimulating hormone and luteinizing hormone levels with repeated measures. The examples provided can serve as stepping stones for more complicated models, tailored to the specific needs of the individual researcher.