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Objectives: To determine the effectiveness of advance care planning (ACP) in frail older adults., Design: Cluster randomized controlled trial., Setting: Residential care homes in the Netherlands (N=16)., Participants: Care home residents and community-dwelling adults receiving home care (N=201; n=101 intervention; n=100 control). Participants were 75 years and older, frail, and capable of consenting to participation., Intervention: Adjusted Respecting Choices ACP program., Measurements: The primary outcome was change in patient activation (Patient Activation Measure, PAM-13) between baseline and 12-month follow-up. Secondary outcomes included change in quality of life (SF-12), advance directive (AD) completion, and surrogate decision-maker appointment. Use of medical care in the 12 months after inclusion was also assessed. Multilevel analyses were performed, controlling for clustering effects and differences in demographics., Results: Seventy-seven intervention participants and 83 controls completed the follow-up assessment. There were no statistically significant differences between the intervention (-0.26±11.2) and control group (-1.43±10.6) in change scores of the PAM (p=.43) or the SF-12. Of intervention group participants, 93% completed an AD, and 94% appointed a decision-maker. Of control participants, 34% completed an AD, and 67% appointed a decision-maker (p<.001). No differences in the use of medical care were found., Conclusions: ACP did not increase levels of patient activation or quality of life but did increase completion of ADs and appointment of surrogate decision-makers. It did not affect use of medical care., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Objectives To explore and compare sociodemographic, clinical, and neuropsychiatric determinants of dropout and nonadherence in older people participating in an open-label cluster-randomized controlled trial-the Prevention of Dementia by Intensive Vascular care (pre DIVA) trial-over 6 years. Design Secondary analysis. Setting One hundred sixteen general practices in the Netherlands. Participants Community-dwelling individuals aged 70 to 78 (N = 2,994). Intervention Nurse-led multidomain intervention targeting cardiovascular risk factors to prevent dementia. Measurements The associations between participant baseline sociodemographic (age, sex, education), clinical (medical history, disability, cardiovascular risk), neuropsychiatric (depressive symptoms (Geriatric Depression Scale-15), and cognitive (Mini-Mental State Examination)) characteristics and dropout from the trial and nonadherence to the trial intervention were explored using multilevel logistic regression models. Results Older age, poorer cognitive function, more symptoms of depression, and greater disability were the most important determinants of dropout of older people. The presence of cardiovascular risk factors was not associated with dropout but was associated with nonadherence. Being overweight was a risk factor for nonadherence, whereas people with high blood pressure or a low level of physical exercise adhered better to the intervention. The association between poorer cognitive function and symptoms of depression and dropout was stronger in the control group than in the intervention group, and vice versa for increased disability. Conclusion In a large dementia prevention trial with 6-year follow-up, dropout was associated with older age, poorer cognitive function, symptoms of depression, and disability at baseline. These findings can help to guide the design of future dementia prevention trials in older adults. The associations found between cardiovascular risk factors and nonadherence need to be confirmed in other older populations receiving cardiovascular prevention interventions. [ABSTRACT FROM AUTHOR]

Objectives To determine the effectiveness of a proactive primary care program on the daily functioning of older people in primary care. Design Single-blind, three-arm, cluster-randomized controlled trial with 1-year follow-up. Setting Primary care setting, 39 general practices in the Netherlands. Participants Community-dwelling people aged 60 and older (N = 3,092). Interventions A frailty screening intervention using routine electronic medical record data to identify older people at risk of adverse events followed by usual care from a general practitioner; after the screening intervention, a nurse-led care program consisting of a comprehensive geriatric assessment, evidence-based care planning, care coordination, and follow-up; usual care. Measurements Primary outcome was daily functioning measured using the Katz-15 (6 activities of daily living ( ADLs), 8 instrumental activities of daily living ( IADLs), one mobility item (range 0-15)); higher scores indicate greater dependence. Secondary outcomes included quality of life, primary care consultations, hospital admissions, emergency department visits, nursing home admissions, and mortality. Results The participants in both intervention arms had less decline in daily functioning than those in the usual care arm at 12 months (mean Katz-15 score: screening arm, 1.87, 95% confidence interval ( CI) = 1.77-1.97; screening and nurse-led care arm, 1.88, 95% CI = 1.80-1.96; control group, 2.03, 95% CI = 1.92-2.13; P = .03). No differences in quality of life were observed. Conclusion Participants in both intervention groups had less decline than those in the control group at 1-year follow-up. Despite the statistically significant effect, the clinical relevance is uncertain at this point because of the small differences. Greater customizing of the intervention combined with prolonged follow-up may lead to more-robust results. [ABSTRACT FROM AUTHOR]

Objectives: To assess whether implementation of a stepwise multicomponent intervention (STA OP!) is effective in reducing challenging behavior and depression in nursing home residents with advanced dementia., Design: Cluster randomized controlled trial., Setting: Twenty-one clusters (single independent nursing home units) in 12 nursing homes within the Netherlands., Participants: Residents with advanced dementia (N = 288)., Intervention: Staff working on intervention units received comprehensive stepwise multidisciplinary training; the control condition received training on general nursing skills, dementia management and pain without the stepwise component., Measurements: The primary outcome was agitation (Cohen-Mansfield Agitation Inventory (CMAI)). Secondary outcomes included psychotropic medication use, neuropsychiatric symptoms (Neuropsychiatric Inventory-Nursing Home version (NPI-NH)), and symptoms of depression (Cornell Scale for Depression in Dementia (CSDD), Minimum Dataset Depression Rating Scale (MDS-DRS)). Measurements were made at baseline and 3 and 6 months after the intervention. Multilevel analysis and logistical generalized estimating equations were used to test treatment and time effects. Analysis was on an intention-to-treat basis., Results: Multilevel modeling revealed an overall effect of the intervention on challenging behavior and depression; CMAI (mean difference -4.07 points, 95% confidence interval = (CI) = -7.90 to -0.24, P = .02), NPI-NH (mean difference -3.57 points, 95% CI = -6.30 to -0.84, P = .005), CSDD (mean difference -1.59 points, 95% CI = -2.49 to -0.69, P < .001), and MDS-DRS (mean difference -0.96 points, 95% CI = -1.40 to -0.52, P < .001) scores were significantly lower in the intervention condition than the control condition. There was a significant reduction of antidepressants (N06A) (OR = 0.32); nonsignificant reductions of antipsychotics (N05A), anxiolytics (N05B), and hypnotic-sedatives (N05C) (odds ratios = 0.69 to 0.90)., Conclusion: For nursing home residents with advanced dementia and challenging behavior, providing staff with comprehensive training in behavioral management, resulted in improved behavior and less psychotropic medication use., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objectives To compare the effects of two exercise programs on proxy- and performance-based measures of activities of daily living ( ADLs) and to explore potential motor and cognitive mediators underlying ADL improvements in individuals with dementia. Design A parallel, three-group, single-blind, randomized, controlled trial. Setting Psychogeriatric wards. Participants Individuals with dementia (mean age 85.6 ± 5.1). Interventions Each 9-week intervention consisted of thirty-six 30-minute sessions. A combined group (n = 35) participated in two strength and two walking sessions, an aerobic group (n = 35) participated in four walking sessions, and a social control group (n = 35) participated in four nonexercise social visits per week. The social group was used as a reference for the mediation analysis, which was performed in the combined and aerobic groups. Measurements ADLs were assessed using the Katz index (proxy-reported ADL performance), Erlangen- ADL test (E- ADL) (instrumental ADL performance), and 7-item Physical Performance Test ( PPT-7) (physical ADL performance). Results There was a group effect for Katz index ( P = .02), E- ADL ( P < .001), and PPT-7 ( P = .003). Differences from baseline to after the intervention were similar in the combined and aerobic groups. Exercise-induced changes in global cognition mediated changes in Katz index (95% confidence interval ( CI) = 0.05-0.41), leg muscle strength mediated changes in E- ADL (95% CI = 0.03-0.43), and leg muscle strength (95% CI = 0.01-0.36) and walking endurance (95% CI = 0.01-0.43) mediated changes in PPT-7 only in the combined group. Conclusion Physical exercise can improve ADL levels in individuals with dementia, but improvements are small and seem independent of exercise type. Additional analyses suggest that combined aerobic and strength exercise may be more effective than aerobic-only exercise to effectively target ADL dysfunction in individuals with dementia. Future research is warranted to justify these exercise-specific findings. [ABSTRACT FROM AUTHOR]

Medical students may not be adequately trained to prescribe appropriately to older adults with polypharmacy. This study addressed how to teach students to minimize inappropriate polypharmacy. Final-year medical students (N = 106) from two Dutch schools of medicine participated in this randomized controlled trial with a pre/posttest design. The Systematic Tool to Reduce Inappropriate Prescribing ( STRIP) was used as the intervention. This medication review tool consists of five steps and is part of the Dutch multidisciplinary guideline on polypharmacy. Step two is a structured pharmaceutical analysis of drug use, assessed using six questions regarding undertreatment, ineffective treatment, overtreatment, potential adverse effects, contraindications or interactions, and dose adjustments. It is used in combination with the Screening Tool to Alert doctors to Right Treatment and the Screening Tool of Older Person's Prescriptions checklists. Students were asked to optimize the medication lists of real people, making use, or not, of the STRIP. The number of correct or potentially harmful decisions that the students made when revising the lists was determined by comparison with expert consensus. Students who used the STRIP had better scores than control students; they made more correct decisions (9.3 vs 7.0, 34%; P < .001, correlation coefficient ( r) = 0.365) and fewer potentially harmful decisions (3.9 vs 5.6, −30%; P < .001, r = 0.386). E-learning did not have a different effect from that of non-E-learning methods. Students were satisfied with the method. The STRIP method is effective in helping final-year medical students improve their prescribing skills. [ABSTRACT FROM AUTHOR]

Objectives: To investigate whether the preventive use of cranberry capsules in long-term care facility (LTCF) residents is cost-effective depending on urinary tract infection (UTI) risk., Design: Economic evaluation with a randomized controlled trial., Setting: Long-term care facilities., Participants: LTCF residents (N = 928, 703 female, median age 84), stratified according to UTI risk., Measurements: UTI incidence (clinically or strictly defined), survival, quality of life, quality-adjusted life years (QALYs), and costs., Results: In the weeks after a clinical UTI, participants showed a significant but moderate deterioration in quality of life, survival, care dependency, and costs. In high-UTI-risk participants, cranberry costs were estimated at €439 per year (1.00 euro = 1.37 U.S. dollar), which is €3,800 per prevented clinically defined UTI (95% confidence interval = €1,300-infinity). Using the strict UTI definition, the use of cranberry increased costs without preventing UTIs. Taking cranberry capsules had a 22% probability of being cost-effective compared with placebo (at a willingness to pay of €40,000 per QALY). In low-UTI-risk participants, use of cranberry capsules was only 3% likely to be cost-effective., Conclusion: In high-UTI-risk residents, taking cranberry capsules may be effective in preventing UTIs but is not likely to be cost-effective in the investigated dosage, frequency, and setting. In low-UTI-risk LTCF residents, taking cranberry capsules twice daily is neither effective nor cost-effective.

OBJECTIVES: To assess whether a pragmatic multidisciplinary fall-prevention program was more effective than usual care in preventing new falls and functional decline in elderly people. DESIGN: A two-group, randomized, controlled trial with 12 months of follow-up. SETTING: University hospital and home-based intervention, the Netherlands. PARTICIPANTS: Three hundred thirty-three community-dwelling Dutch people aged 65 and over who were seen in an emergency department after a fall. INTERVENTION: Participants in the intervention group underwent a detailed medical and occupational-therapy assessment to evaluate and address risk factors for recurrent falls, followed by recommendations and referral if indicated. People in the control group received usual care. MEASUREMENTS: Number of people sustaining a fall (fall calendar) and daily functioning (Frenchay Activity Index). RESULTS: Results showed no statistically significantly favorable effects on falls (odds ratio=0.86, 95% confidence interval (CI)=0.50–1.49) or daily functioning (regression coefficient=0.37, CI=−0.90 to 1.63) after 12 months of follow-up. CONCLUSION: The multidisciplinary fall-prevention program was not effective in preventing falls and functional decline in this Dutch healthcare setting. Implementing the program in its present form in the Netherlands is not recommended. This trial shows that there can be considerable discrepancy between the “ideal” (experimental) version of a program and the implemented version of the same program. The importance of implementation research in assessing feasibility and effectiveness of such a program in a specific healthcare setting is therefore stressed. [ABSTRACT FROM AUTHOR]

To determine whether a functional-task exercise program and a resistance exercise program have different effects on the ability of community-living older people to perform daily tasks.A randomized, controlled, single-blind trial.Community leisure center in Utrecht, the Netherlands.Ninety-eight healthy women aged 70 and older were randomly assigned to the functional-task exercise program (function group, n=33), a resistance exercise program (resistance group, n=34), or a control group (n=31). Participants attended exercise classes three times a week for 12 weeks.Functional task performance (Assessment of Daily Activity Performance (ADAP)), isometric knee extensor strength (IKES), handgrip strength, isometric elbow flexor strength (IEFS), and leg extension power were measured at baseline, at the end of training (at 3 months), and 6 months after the end of training (at 9 months).The ADAP total score of the function group (mean change 6.8, 95% confidence interval (CI)=5.2–8.4) increased significantly more than that of the resistance group (3.2, 95% CI=1.3–5.0;P=.007) or the control group (0.3, 95% CI=−1.3–1.9;P<.001). Moreover, the ADAP total score of the resistance group did not change significantly compared with that of the control group. In contrast, IKES and IEFS increased significantly in the resistance group (12.5%, 95% CI=3.8–21.3 and 8.6%, 95% CI=3.1–14.1, respectively) compared with the function group (−2.1%, 95% CI=−5.4–1.3;P=.003 and 0.3%, 95% CI=−3.6–4.2;P=.03, respectively) and the control group (−2.7%, 95% CI=−8.6–3.2,P=.003 and 0.6%, 95% CI=−3.4–4.6;P=.04, respectively). Six months after the end of training, the increase in ADAP scores was sustained in the function group (P=.002).Functional-task exercises are more effective than resistance exercises at improving functional task performance in healthy elderly women and may have an important role in helping them maintain an independent lifestyle. [ABSTRACT FROM AUTHOR]

The article reports on research which was conducted to compare the effectiveness of music therapy and traditional recreational activities in treating the neuropsychiatric symptoms of elderly adults with dementia. Researchers evaluated 94 nursing home residents. They found that residents receiving music therapy showed greater reductions in neuropsychiatric symptoms than those receiving recreational activities.

Objectives To evaluate the cost-effectiveness of the Geriatric Care Model ( GCM), an integrated care model for frail older adults based on the Chronic Care Model, with that of usual care. Design Economic evaluation alongside a 24-month stepped-wedge cluster-randomized controlled trial. Setting Primary care (35 practices) in two regions in the Netherlands. Participants Community-dwelling older adults who were frail according to their primary care physicians and the Program on Research for Integrating Services for the Maintenance of Autonomy case-finding tool questionnaire (N = 1,147). Intervention The GCM consisted of the following components: a regularly scheduled in-home comprehensive geriatric assessment by a practice nurse followed by a customized care plan, management and training of practice nurses by a geriatric expert team, and coordination of care through community network meetings and multidisciplinary team consultations of individuals with complex care needs. Measurements Outcomes were measured every 6 months and included costs from a societal perspective, health-related quality of life (Medical Outcomes Study 12-item Short-Form Survey ( SF-12) physical ( PCS) and mental component summary ( MCS) scales), functional limitations (Katz activities of daily living and instrumental activities of daily living), and quality-adjusted life years based on the EQ-5D. Results Multilevel regression models adjusted for time and baseline confounders showed no significant differences in costs ($356, 95% confidence interval = −$488-1,134) and outcomes between intervention and usual care phases. Cost-effectiveness acceptability curves showed that, for the SF-12 PCS and MCS, the probability of the intervention being cost-effective was 0.76 if decision-makers are willing to pay $30,000 per point improvement on the SF-12 scales (range 0-100). For all other outcomes the probability of the intervention being cost-effective was low. Conclusion Because the GCM was not cost-effective compared to usual care after 24 months of follow-up, widespread implementation in its current form is not recommended. [ABSTRACT FROM AUTHOR]

Objectives To examine changes in motor subtype profile in individuals with delirium. Design Observational, longitudinal study; substudy of a multicenter, randomized controlled trial. Setting Departments of surgery and orthopedics, Academic Medical Center and Tergooi Hospital, the Netherlands. Participants Elderly adults acutely admitted for hip fracture surgery who developed delirium according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, for 2 days or longer (n = 76, aged 86.4 ± 6.1, 68.4% female). Measurements Delirium Motor Subtype Scale ( DMSS), Delirium Rating Scale R98 ( DRS-R98), comorbidity, and function. Results Median delirium duration was 3 days (interquartile range 2.0 days). At first assessment, the hyperactive motor subtype was most common (44.7%), followed by hypoactive motor subtype (28.9%), mixed motor subtype (19.7%), and no motor subtype (6.6%). Participants with no motor subtype had lower DRS-R98 scores than those with the other subtypes ( P < .001). The DMSS-defined motor subtype of 47 (61.8%) participants changed over time. Katz Index of Activities of Daily Living, Charlson Comorbidity Index, cognitive impairment, age, sex, and delirium duration or severity were not associated with change in motor subtype. Conclusion Motor subtype profile was variable in the majority of participants, although changes that occurred were often related to changes from or to no motor subtype, suggesting evolving or resolving delirium. Changes appeared not be associated with demographic or clinical characteristics, suggesting that evidence from cross-sectional studies of motor subtypes could be applied to many individuals with delirium. Further longitudinal studies should be performed to clarify the stability of motor subtypes in different clinical populations. [ABSTRACT FROM AUTHOR]

Objectives To assess the association between serum S100B levels (a marker of brain damage), delirium, and subsequent cognitive decline. Design Substudy of a multicenter randomized controlled trial. Setting Surgical, orthopedic, and trauma surgery wards of two teaching hospitals. Participants Individuals aged 65 and older (range 65-102) admitted for hip fracture surgery (N = 385). Measurements During hospitalization, presence of delirium was assessed daily. S100B was assayed in repeated serum samples. Twelve months after discharge, cognitive decline and mortality were evaluated. Cognitive decline was defined as an increase in Informant Questionnaire on Cognitive Decline Short Form score of 1 standard deviation or more or a decrease in Mini Mental State Examination score of 3 points or more between admission and 12 months after discharge. Results Premorbid cognitive impairment was present in 226 (58.7%) participants, and 127 (33.0%) experienced perioperative delirium. Multivariable analysis showed that older age and presence of infection, but not of delirium, were associated with higher S100B levels. Levels were also higher after surgery than before. Of participants with perioperative delirium, 58.6% experienced cognitive decline or death, and only age was a risk factor; 36.5% of participants without perioperative delirium experienced cognitive decline or death in the following year, and higher S100B, premorbid cognitive impairment, and older age were risk factors. Conclusion In a cohort of older adults with hip fracture, no association was found between serum S100B levels and occurrence of delirium. S100B was associated with cognitive decline or death in the first year after hip fracture only in participants without perioperative delirium. S100B seems to be of limited value as a biomarker of brain damage associated with delirium. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate the effectiveness of Tai Chi Chuan in fall prevention in elderly people living at home with a high risk of falling. DESIGN: Randomized controlled trial. SETTING: Two industrial towns in the western part of the Netherlands. PARTICIPANTS: Two hundred sixty-nine elderly people (average age 77) living at home with a high risk of falling. INTERVENTIONS: The intervention group received Tai Chi Chuan training for 1 hour twice a week for 13 weeks; the control group received usual care. Both groups received a brochure containing general information on how to prevent fall incidents. MEASUREMENTS: Primary outcome was the number of falls over 12 months. Secondary outcomes were balance, fear of falling, blood pressure, heart rate at rest, forced expiratory volume during the first second, peak expiratory flow, physical activity, and functional status. RESULTS: After 12 months, no lower fall risk in the Tai Chi Chuan group was observed than in the control group (adjusted hazard ratio=1.16; 95% confidence interval=0.84–1.60), and there were no significant intervention effects on the secondary outcome measures. CONCLUSION: These results suggest that Tai Chi Chuan may not be effective in elderly people at a high risk of falling who live at home. [ABSTRACT FROM AUTHOR]

Background/objectives: Telephone follow-up calls could optimize the transition from the emergency department (ED) to home for older patients. However, the effects on hospital return rates are not clear. We investigated whether telephone follow-up reduces unplanned hospitalizations and/or unplanned ED return visits within 30 days of ED discharge., Design: Pragmatic randomized controlled trial with allocation by month; odd months intervention group, even months control group., Setting: Two ED locations of a non-academic teaching hospital in The Netherlands., Participants: Community-dwelling adults aged ≥70 years, discharged home from the ED were randomized to the intervention group (N = 4732) or control group (N = 5104)., Intervention: Intervention group patients: semi-scripted telephone call from an ED nurse within 24 h after discharge to identify post-discharge problems and review discharge instructions. Control group patients: scripted satisfaction survey telephone call., Measurements: Primary outcome: total number of unplanned hospitalizations and/or ED return visits within 30 days of ED discharge., Secondary Outcomes: separate numbers of unplanned hospitalizations and ED return visits. Subgroup analysis by age, sex, living condition, and degree of crowding in the ED at discharge., Results: Overall, 42% were males, and median age was 78 years. In the intervention group, 1516 of 4732 patients (32%) consented, and in the control group 1659 of 5104 (33%) patients. Unplanned 30-day hospitalization and/or ED return visit was found in 16% of intervention group patients and 14% of control group patients (odds ratio 1.16; 95% confidence interval: 0.96-1.42). Also, no statistically significant differences were found in secondary outcome measures. Within the subgroups, the intervention did not have beneficial effects for the intervention group., Conclusion: Telephone follow-up after ED discharge in older patients did not result in reduction of unplanned hospital admissions and/or ED return visits within 30 days. These results raise the question of whether other outcomes could be improved by post-discharge ED telephone follow-up., (© 2021 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Objectives: To examine the association between blood pressure (BP) measures and symptoms of apathy and depression in older adults with various levels of functional ability., Design: Cross-sectional study using baseline data from the Discontinuation of Antihypertensive Treatment in Elderly people (DANTE) Study Leiden., Setting: Primary care setting, the Netherlands., Participants: Community-dwelling individuals aged 75 and older (N = 430)., Measurements: Systolic BP (SBP), diastolic BP (DBP), and mean arterial pressure (MAP) were measured during home visits. Symptoms of apathy and depression were assessed using the Apathy Scale and the Geriatric Depression Scale (GDS-15), respectively. Stratified linear regression was performed in participants with better and worse functional ability according to the median of the Groningen Activity Restriction Scale., Results: In participants with lower functional ability, each 10-mmHg lower SBP, DBP, and MAP was associated with higher Apathy Scale scores (0.63, 0.92, and 0.94 points, respectively, all P < .005) but not with GDS-15 scores. In participants with higher functional ability, BP measures were not associated with Apathy Scale or GDS-15 scores., Conclusion: In older participants with poorer functional ability, lower BP was associated with more symptoms of apathy but not depression., (© 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.)

Objectives: To determine the effect of fall-related concerns on physical, mental, and social function., Design: Community-based prospective cohort study (secondary analysis using control group data from a randomized controlled trial)., Setting: Two municipalities in the south of the Netherlands., Participants: Community-dwelling older adults (N = 260)., Measurements: Two groups were created using Modified Falls Efficacy Scale scores (high and low levels of fall-related concerns). Five outcome measures representing physical, mental, and social function were included: activities of daily living (ADLs), symptoms of depression, feelings of anxiety, social participation, and social support interactions. Outcomes were measured at baseline and at 2, 8, and 14 months. Data were analyzed using analysis of covariance and mixed-effect regression models for longitudinal data, adjusting for age, sex, living status (alone or with another person), educational level, cognitive status, self-perceived health, and falls history at baseline., Results: At baseline, significantly more limitations in ADLs and social participation were found for older persons with high levels of fall-related concerns than for those with low levels of concern. These differences persisted over 14 months of follow-up and were consistent over time. No significant differences were found for symptoms of depression, feelings of anxiety, or social support interactions, except for feelings of anxiety at 14 months., Conclusion: Older persons with higher levels of fall-related concerns reported up to 14 months poorer ADL and social participation for up to 14 months than those with lower levels of fall-related concerns. From a clinical point of view, the clear relationship between fall-related concerns and ADL dysfunction and social participation may help to target groups who are at risk of developing adverse consequences of concerns about falls., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

Objectives: To assess the effect of preventive pravastatin treatment on coronary heart disease (CHD) morbidity and mortality in older persons at risk for cardiovascular disease (CVD), stratified according to plasma levels of homocysteine., Design: A post hoc subanalysis in the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER), started in 1997, which is a double-blind, randomized, placebo-controlled trial with a mean follow-up of 3.2 years., Setting: Primary care setting in two of the three PROSPER study sites (Netherlands and Scotland)., Participants: Individuals (n = 3,522, aged 70-82, 1,765 male) with a history of or risk factors for CVD were ranked in three groups depending on baseline homocysteine level, sex, and study site., Intervention: Pravastatin (40 mg) versus placebo., Measurements: Fatal and nonfatal CHD and mortality., Results: In the placebo group, participants with a high homocysteine level (n = 588) had a 1.8 higher risk (95% confidence interval (CI) = 1.2-2.5, P = .001) of fatal and nonfatal CHD than those with a low homocysteine level (n = 597). The absolute risk reduction in fatal and nonfatal CHD with pravastatin treatment was 1.6% (95% CI = -1.6 to 4.7%) in the low homocysteine group and 6.7% (95% CI = 2.7-10.7%) in the high homocysteine group (difference 5.2%, 95% CI = 0.11-10.3, P = .046). Therefore, the number needed to treat (NNT) with pravastatin for 3.2 years for benefit related to fatal and nonfatal CHD events was 14.8 (95% CI = 9.3-36.6) for high homocysteine and 64.5 (95% CI = 21.4-∞) for low homocysteine., Conclusion: In older persons at risk of CVD, those with high homocysteine are at highest risk for fatal and nonfatal CHD. With pravastatin treatment, this group has the highest absolute risk reduction and the lowest NNT to prevent fatal and nonfatal CHD., (© 2014, Copyright the Authors. Journal compilation © 2014, The American Geriatrics Society.)

Objectives: To determine whether cranberry capsules prevent urinary tract infection (UTI) in long-term care facility (LTCF) residents., Design: Double-blind randomized placebo-controlled multicenter trial., Setting: Long-term care facilities (LTCFs)., Participants: LTCF residents (N = 928; 703 women, median age 84)., Measurements: Cranberry and placebo capsules were taken twice daily for 12 months. Participants were stratified according to UTI risk (risk factors included long-term catheterization, diabetes mellitus, ≥ 1 UTI in preceding year). Main outcomes were incidence of UTI according to a clinical definition and a strict definition., Results: In participants with high UTI risk at baseline (n = 516), the incidence of clinically defined UTI was lower with cranberry capsules than with placebo (62.8 vs 84.8 per 100 person-years at risk, P = .04); the treatment effect was 0.74 (95% confidence interval (CI) = 0.57-0.97). For the strict definition, the treatment effect was 1.02 (95% CI = 0.68-1.55). No difference in UTI incidence between cranberry and placebo was found in participants with low UTI risk (n = 412)., Conclusion: In LTCF residents with high UTI risk at baseline, taking cranberry capsules twice daily reduces the incidence of clinically defined UTI, although it does not reduce the incidence of strictly defined UTI. No difference in incidence of UTI was found in residents with low UTI risk.

Objectives: To investigate the effect of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) supplementation on quality of life (QOL)., Design: Randomized, double-blind, placebo-controlled trial., Setting: Independently living individuals from the general older Dutch population., Participants: Three hundred two individuals aged 65 and older without depression or dementia., Intervention: 1,800 mg/d EPA-DHA (n=96), 400 mg/d EPA-DHA (n=100), or placebo capsules (n=106) for 26 weeks., Measurements: QOL was assessed using the short version of the World Health Organization QOL questionnaire (WHOQOL-BREF). The WHOQOL-BREF covers four domains: physical health, psychological health, social relationships, and satisfaction with environment. The total score range is 26 to 130, with higher scores indicating a more favorable condition., Results: Mean age of the participants was 70, and 55% were male. Plasma concentrations of EPA-DHA increased 238% in the high-dose and 51% in the low-dose EPA-DHA group, reflecting excellent adherence. Median baseline total WHOQOL scores ranged from 107 to 110 in the three groups and were not significantly different from each other. After 26 weeks, the mean difference from placebo was -1.42 (95% confidence interval (CI)=-3.40-0.57) for the high-dose and 0.02 (95% CI=-1.95-1.99) for the low-dose fish oil group. Treatment with 1,800 mg or 400 mg EPA-DHA did not affect total QOL or any of the separate domains after 13 or 26 weeks of intervention., Conclusion: Supplementation with high or low doses of fish oil for 26 weeks did not influence the QOL of healthy older individuals.

Objectives: To investigate whether vascular care slows dementia progression in patients with Alzheimer's disease with cerebrovascular lesions on neuroimaging., Design: Multicenter randomized controlled clinical trial with 2-year follow-up., Setting: Neurological and geriatric outpatient clinics in 10 Dutch hospitals: three academic, five teaching, and two midsize community hospitals., Participants: One hundred thirty community-dwelling patients with mild dementia fulfilling clinical criteria for Alzheimer's disease with cerebrovascular lesions on neuroimaging., Intervention: Patients randomized to vascular care were treated according to strict guidelines for hypercholesterolemia and hypertension. Acetylsalicylic acid, folic acid, and pyridoxine were prescribed. During visits every 3 months special attention was paid to smoking cessation, losing weight, and stimulating physical exercise., Measurements: Primary outcome was disability, measured according to the Interview for Deterioration in Daily activities in Dementia (IDDD). Secondary outcomes were changes on the Mini-Mental State Examination (MMSE), the Revised Memory and Behavioural Problems Checklist (RMBPC), a composite measure of "poor outcome" (death, institutionalization, or severe clinical decline), and costs., Results: Patients in the vascular and standard care condition declined equally on the IDDD (13.7 vs 11.0 points; difference 2.7, 95% confidence interval = -3.1-8.6). There was no treatment effect on the MMSE or RMBPC. There were no differences in institutionalization rate, "poor outcome" (41.4% vs 35.4%, P=.50), or costs. In the intervention group, there were three intracerebral hemorrhages and one gastrointestinal hemorrhage, versus none in the control group., Conclusion: Multicomponent vascular care, combining pharmacological and nonpharmacological interventions, does not slow decline in patients with Alzheimer's disease with cerebrovascular lesions.

Objectives: To investigate the association between antipsychotic drug use and risk of pneumonia in elderly people., Design: A nested case-control analysis., Setting: Data were used from the PHARMO database, which collates information from community pharmacies and hospital discharge records., Participants: A cohort of 22,944 elderly people with at least one antipsychotic prescription; 543 cases of hospital admission for pneumonia were identified. Cases were compared with four randomly selected controls matched on index date., Measurements: Antipsychotic drug use in the year before the index date was classified as current, recent, or past use. No prescription for an antipsychotic in the year before the index date was classified as no use. The strength of the association between use of antipsychotics and the development of pneumonia was estimated using multivariate logistic regression analysis and expressed as odds ratios (ORs) with 95% confidence intervals (CIs)., Results: Current use of antipsychotics was associated with an almost 60% increase in the risk of pneumonia (adjusted OR=1.6, 95% CI=1.3-2.1). The risk was highest during the first week after initiation of an antipsychotic (adjusted OR=4.5, 95% CI=2.8-7.3). Similar associations were found after exclusion of elderly people with a diagnosis of delirium. Current users of atypical agents showed a higher risk of pneumonia (adjusted OR=3.1, 95% CI=1.9-5.1) than users of conventional agents (adjusted OR=1.5, 95% CI=1.2-1.9). There was no clear dose-response relationship., Conclusion: Use of antipsychotics in elderly people is associated with greater risk of pneumonia. This risk is highest shortly after the initiation of treatment, with the greatest increase in risk found for atypical antipsychotics.

Objectives: To evaluate the effectiveness of a home visiting program on health-related measures in a population of older people with poor health status., Design: Randomized, clinical trial., Setting: Community-dwelling citizens in The Netherlands., Participants: Three hundred thirty people aged 70 to 84 randomly assigned to an intervention group (n=160) or a control group (n=170)., Intervention: Eight home visits, lasting 1 hour or more, with telephone follow-up, over an 18-month period, conducted by experienced home nurses under supervision of a public health nurse; key elements of the (systematic) visits were assessment of health problems and risks, advice, and referral to professional and community services., Measurements: Self-rated health, functional status, quality of life, and changes in self-reported problems., Results: No differences were found between the intervention and control group in these and other outcome measures at the end of the intervention period (18 months)., Conclusion: The home visiting program did not appear to have any effect on the health status of older people with poor health and are probably not beneficial for such persons.