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Background. Depression and cognitive functioning have a negative impact on functional recovery after hip fracture surgery in older people, and the same has been suggested for pain and fear of falling. These variables, however, have never been studied together, nor has the timing of psychiatric assessment been taken into account.Method. Two parallel, randomized controlled trials were undertaken aiming to prevent and treat depression after hip fracture surgery in older people. Multiple logistic regression analyses corrected for age and pre-morbid level of functioning were performed to evaluate the effect of depressive symptoms (15-item Geriatric Depression Scale, GDS), pain (Wong–Baker pain scale), cognitive functioning (Mini-mental State Examination, MMSE) and fear of falling (Modified Falls Efficacy Scale, MFES) within 2 weeks after surgery and 6 weeks later on functional recovery at 6 months. Main outcome measures were performance-based measures (up-and-go test, gait test, functional reach) and the self-report Sickness Impact Profile (SIP) questionnaire to assess the impact of the hip fracture on activities of daily living (ADL).Results. Two hundred and ninety-one patients participated and outcome measures for 187 (64%) patients were available at 6 months. All mental health variables interfered with functional recovery. However, in the final multivariate model, cognitive functioning and fear of falling assessed 6 weeks after surgery consistently predicted functional recovery, whereas pain and depressive symptoms were no longer significant.Conclusion. Fear of falling and cognitive functioning may be more important than pain and depression to predict functional recovery after hip fracture surgery. Rehabilitation strategies should take this into account. [ABSTRACT FROM AUTHOR]

Abstract Background People with dementia and severe challenging behavior in the Netherlands can be temporarily admitted to highly specialized units when their behavior is not manageable in regular dementia special care units (DSCUs). With scarce evidence available for the treatment of these patients, treatment in these units is in a pioneering phase. To gain more insight into these units, this study investigated organizational characteristics, i.e. admission and discharge characteristics, staffing, the physical environment, and the management of severe challenging behavior. Methods Three data collection methods were used: 1) a digital questionnaire to be completed by the unit manager, 2) an interview with the physician responsible for medical care and often another practitioner, and 3) an observation of the physical environment for which the OAZIS-dementia questionnaire was used. Descriptive analysis was used for quantitative data and thematic analysis for qualitative data, after which data was interpreted together. Thirteen units participated, with their sizes ranging from 10 to 28 places. Results Patients were mainly admitted from regular DSCUs, home or mental health care, and discharged to regular DSCUs. A multidisciplinary team comprising at least an elderly care physician or geriatrician, psychologist, and nursing staff member and other therapists as needed provided the treatment. Nursing staff hours per patient considerably differed among units. Nursing staff played a central role in the treatment. Competences such as reflectiveness on one’s own behavior, and being able to cope with stressful situations were described as relevant for nursing staff. Investing in a stable nursing staff team was described as important. The units varied in whether their work-up was more intuitive or methodological. In the diagnostic phase, observation together with an extensive analysis of the patient’s biography was essential. The units used a broad variety of interventions, and all paid attention to sensory stimuli. In the observation of the physical environment, the safety scored well and domesticity relatively low. Conclusion Highly specialized units show strong heterogeneity in organizational characteristics and management, which can be understood in the light of the pioneering phase. Despite this, similarities were found in nursing staff roles, frequent multidisciplinary evaluation, and attention to sensory stimuli.

Abstract Background Evidence on the effectiveness of multidomain lifestyle interventions to prevent cognitive decline in older people without dementia is mixed. Embedded in the World-Wide FINGERS initiative, FINGER-NL aims to investigate the effectiveness of a 2-year multidomain lifestyle intervention on cognitive functioning in older Dutch at risk individuals. Methods Multi-center, randomized, controlled, multidomain lifestyle intervention trial with a duration of 24 months. 1210 adults between 60–79 years old with presence of ≥ 2 modifiable risk factors and ≥ 1 non-modifiable risk factor for cognitive decline were recruited between January 2022 and May 2023 via the Dutch Brain Research Registry and across five study sites in the Netherlands. Participants were randomized to either a high-intensity or a low-intensity intervention group. The multidomain intervention comprises a combination of 7 lifestyle components (physical activity, cognitive training, cardiovascular risk factor management, nutritional counseling, sleep counseling, stress management, and social activities) and 1 nutritional product (Souvenaid®) that could help maintain cognitive functioning. The high-intensity intervention group receives a personalized, supervised and hybrid intervention consisting of group meetings (on-site and online) and individual sessions guided by a trained lifestyle coach, and access to a digital intervention platform that provides custom-made training materials and selected lifestyle apps. The low-intensity intervention group receives bi-monthly online lifestyle-related health advice via the digital intervention platform. Primary outcome is 2-year change on a cognitive composite score covering processing speed, executive function, and memory. Results Within 17 months, participant recruitment has been successfully completed (N = 1210; mean age: 67.7 years (SD: 4.6); 64% female). Modifiable risk factors commonly present at baseline were physical inactivity (89%), low mental/cognitive activity (50%), low social engagement (39%), hypertension (39%) and high alcohol consumption (39%). The mean body mass index of participants was 28.3 (SD: 4.2) and the total serum cholesterol was 5.4 mmol/L (SD: 1.2). Conclusions Baseline lifestyle and clinical measurements showed successful recruitment of participants with sufficient potential for prevention. Results of FINGER-NL will provide further insight into the efficacy of a multidomain lifestyle intervention to prevent cognitive decline in older adults. Trial registration ClinicalTrials.gov (ID: NCT05256199)/2022–01-11.

ABSTRACT Objective To evaluate the direct and indirect effects of chronic pain, depressive symptoms, frailty components, and functional disability through a pathway analysis approach in a sample of community-dwelling older adults. Methods Data of 419 participants were cross-sectionally evaluated for the presence of depressive symptoms (Geriatric Depression Scale [15 items]), physical frailty components (phenotype criteria), chronic pain, and limitations in performing instrumental activities of daily living (functional disability scale by Lawton and Brody). Structural equation modeling via path analysis was used to explore the direct and indirect effects among these four variables. Statistical significance was set at p

Abstract Background Comorbidity between depression and cognitive impairment is common in older adults, increases the disease burden disproportionally, and leads to diagnostic uncertainty. Insight into individual daily associations between affect and cognitive performance may help in personalizing diagnosis and treatment decisions. Our objective was to get insight into the daily associations between affect and cognitive performance within individual older adults. Methods In this single-subject study seven older adults with both depression and cognitive impairment filled in electronic diaries daily for 62-93 consecutive days evaluating positive affect (PA), negative affect (NA), working memory (WM) and visual learning (VL). Time-series analyses using vector autoregressive modelling, Granger causality tests and cumulative orthogonalized impulse response function analyses were performed for each individual separately. Results In one patient higher NA was associated with better WM the next day. For another patient days with higher NA and lower PA were days with worse WM. For a third patient better VL was associated with lower NA and higher PA the next day. No associations were found for four patients. Conclusions These results highlight heterogeneity in the daily associations between affect and cognitive performance and stress the relevance of single-subject studies. These studies may be an important step towards personalized diagnosis and treatment in old age psychiatry.

Abstract Background Recovery in mental health care comprises more than symptomatic improvement, but preliminary evidence suggests that only collaborative care may improve functioning of depressed older adults. This study therefore evaluates the effectiveness of behavioural activation (BA) on functional limitations in depressed older adults in primary care. Methods This study uses data from a multicentre cluster randomised controlled trial in which 59 primary care centres (PCCs) were randomised to BA and treatment as usual (TAU), and 161 consenting older (≥65 years) adults with clinically relevant symptoms of depression participated. Interventions were an eight-week individual BA programme by a mental health nurse (MHN) and unrestricted TAU. The outcome was self-reported functional limitations (WHODAS 2.0) at post-treatment (9 weeks) and at 12-month follow-up. Results At the end of treatment, the BA participants reported significantly fewer functional limitations than TAU participants (WHODAS 2.0 difference −3.62, p = 0.01, between-group effect size = 0.39; 95% CI = 0.09–0.69). This medium effect size decreases during follow-up resulting in a small and non-significant effect at the 12-month follow-up (WHODAS 2.0 difference = −2.22, p = 0.14, between-group effect size = 0.24; 95% CI = -0.08–0.56). MoCA score moderated these results, indicating that the between-group differences were merely driven by those with no cognitive impairment. Conclusions Compared to TAU, BA leads to a faster improvement of functional limitations in depressed older adults with no signs of cognitive decline. Replication of these findings in confirmatory research is needed.

Abstract Background To investigate whether an exercise intervention using the VIVIFRAIL© protocol has benefits for inflammatory and functional parameters in different frailty status. Methods/design This is a randomized clinical trial in an outpatient geriatrics clinic including older adults ≥60 years. For each frailty state (frail, pre-frail and robust), forty-four volunteers will be randomly allocated to the control group (n = 22) and the intervention group (n = 22) for 12 weeks. In the control group, participants will have meetings of health education while those in the intervention group will be part of a multicomponent exercise program (VIVIFRAIL©) performed five times a week (two times supervised and 3 times of home-based exercises). The primary outcome is a change in the inflammatory profile (a reduction in inflammatory interleukins [IL-6, TNF- α, IL1beta, IL-17, IL-22, CXCL-8, and IL-27] or an increase in anti-inflammatory mediators [IL-10, IL1RA, IL-4]). Secondary outcomes are change in physical performance using the Short Physical Performance Battery, handgrip strength, fatigue, gait speed, dual-task gait speed, depressive symptoms, FRAIL-BR and SARC-F scores, and quality of life at the 12-week period of intervention and after 3 months of follow-up. Discussion We expect a reduction in inflammatory interleukins or an increase in anti-inflammatory mediators in those who performed the VIVIFRAIL© protocol. The results of the study will imply in a better knowledge about the effect of a low-cost intervention that could be easily replicated in outpatient care for the prevention and treatment of frailty, especially regarding the inflammatory and anti-inflammatory pathways involved in its pathophysiology. Trial registration Brazilian Registry of Clinical Trials (RBR-9n5jbw; 01/24/2020). Registred January 2020. http://www.ensaiosclinicos.gov.br/rg/RBR-9n5jbw/ .

Euthanasia was first legalized in the Netherlands and Belgium in 2001 and 2002, respectively. Currently they are among the few countries that also allow euthanasia on the basis of dementia, which is still considered controversial, both from a scientific and societal perspective. To date, euthanasia in dementia constitutes a small proportion of all Dutch and Belgian euthanasia cases. However, instances are rising due to a growing awareness among the general public about the possibilities of a self-chosen end-of-life and the willingness among medical professionals to perform euthanasia in individuals diagnosed with dementia. In both countries euthanasia is allowed under strict conditions in patients with dementia and decisional capacity regarding euthanasia, while in the Netherlands an advance euthanasia directive can also replace an oral request for euthanasia in those with late-stage dementia. Judging euthanasia requests from patients with dementia is complex and the assessment of the due care criteria (especially those related to decisional capacity and unbearable suffering) requires caution and great care. In this narrative review, we reflect on the legal regulation, clinical guidelines and societal debate regarding euthanasia in dementia in the Netherlands and Belgium. By discussing the 20 years of experience with the ethical dilemmas and controversial aspects surrounding this delicate topic, we hope to inform the preparation or implementation of new legislation on euthanasia in dementia in other countries.

Abstract Background To explore the mutual relationship between multimorbidity, mental illness and frailty, we have set-up the Multimorbidity and Mental health Cohort Study in FRAILty and Aging (MiMiCS-FRAIL) cohort. At the population level, multimorbidity, frailty and late-life depression are associated with similar adverse outcomes (i.e. falls, disability, hospitalization, death), share the same risk factors, and partly overlap in their clinical presentation. Moreover, these three variables may share a common underlying pathophysiological mechanism like immune-metabolic dysregulation. The overall objectives of MiMiCS-FRAIL are 1) to explore (determinants of) the cross-sectional and longitudinal relationship between multimorbidity, depression, and frailty among non-demented geriatric outpatients; 2) to evaluate molecular levels of senoinflammation as a broad pathophysiological process underlying these conditions; and 3) to examine adverse outcomes of multimorbidity, frailty and depression and their interconnectedness. Methods MiMiCS-FRAIL is an ongoing observational cohort study of geriatric outpatients in Brazil, with an extensive baseline assessment and yearly follow-up assessments. Each assessment includes a comprehensive geriatric assessment to identify multimorbidity and geriatric syndromes, a structured psychiatric diagnostic interview and administration of the PHQ-9 to measure depression, and several frailty measures (FRAIL, Physical Phenotype criteria, 36-item Frailty Index). Fasten blood samples are collected at baseline to assess circulating inflammatory and anti-inflammatory cytokines, leukocytes' subpopulations, and to perform immune-metabolic-paired miRome analyses. The primary outcome is death and secondary outcomes are the number of falls, hospital admissions, functional ability, well-being, and dementia. Assuming a 5-year mortality rate between 25 and 40% and a hazard rate varying between 1.6 and 2.3 for the primary determinants require a sample size between 136 and 711 patients to detect a statistically significant effect with a power of 80% (beta = 0.2), an alpha of 5% (0.05), and an R2 between the predictor (death) and all covariates of 0.20. Local ethical board approved this study. Discussion Frailty might be hypothesized as a final common pathway by which many clinical conditions like depression and chronic diseases (multimorbidity) culminate in many adverse effects. The MiMiCS-FRAIL cohort will help us to understand the interrelationship between these variables, from a clinical perspective as well as their underlying molecular signature.

Abstract Background Affective disorders, encompassing depressive-, anxiety-, and somatic symptom disorders, are the most prevalent mental disorders in later life. Treatment protocols and guidelines largely rely on evidence from RCTs conducted in younger age samples and ignore comorbidity between these disorders. Moreover, studies in geriatric psychiatry are often limited to the “younger old” and rarely include the most frail. Therefore, the effectiveness of treatment in routine clinical care for older patients and impact of ageing characteristics is largely unknown. Objective The primary aim of the Routine Outcome Monitoring for Geriatric Psychiatry & Science (ROM-GPS) – project is to examine the impact of ageing characteristics on the effectiveness of treatment for affective disorders in specialised geriatric mental health care. Methods ROM-GPS is a two-stage, multicentre project. In stage one, all patients aged ≥60 years referred to participating outpatient clinics for specialised geriatric mental health care will be routinely screened with a semi-structured psychiatric interview, the Mini International Neuropsychiatric Interview and self-report symptom severity scales assessing depression, generalized anxiety, hypochondria, and alcohol use. Patients with a unipolar depressive, anxiety or somatic symptom disorder will be asked informed consent to participate in a second (research) stage to be extensively phenotyped at baseline and closely monitored during their first year of treatment with remission at one-year follow-up as the primary outcome parameter. In addition to a large test battery of potential confounders, specific attention is paid to cognitive functioning (including computerized tests with the Cogstate test battery as well as paper and pencil tests) and physical functioning (including multimorbidity, polypharmacy, and different frailty indicators). The study is designed as an ongoing project, enabling minor adaptations once a year (change of instruments). Discussion Although effectiveness studies using observational data can easily be biased, potential selection bias can be quantified and potentially corrected (e.g. by propensity scoring). Knowledge of age-related determinants of treatment effectiveness, may stimulate the development of new interventions. Moreover, studying late-life depressive, anxiety and somatic symptom disorders jointly enables data-driven studies for more optimal classification of these disorders in later life. Trial registration Dutch Trial Register: NL6704 (www.trialregister.nl). Retrospectively registered on 2017-12-05.

Major depressive disorder (MDD) affects millions of people worldwide and is a leading cause of disability. Several theories have been proposed to explain its pathological mechanisms, and the “neurotrophin hypothesis of depression” involves one of the most relevant pathways. Brain-derived neurotrophic factor (BDNF) is an important neurotrophin, and it has been extensively investigated in both experimental models and clinical studies of MDD. Robust empirical findings have indicated an association between increased BDNF gene expression and peripheral concentration with improved neuronal plasticity and neurogenesis. Additionally, several studies have indicated the blunt expression of BDNF in carriers of the Val66Met gene polymorphism and lower blood BDNF (serum or plasma) levels in depressed individuals. Clinical trials have yielded mixed results with different treatment options, peripheral blood BDNF measurement techniques, and time of observation. Previous meta-analyses of MDD treatment have indicated that antidepressants and electroconvulsive therapy showed higher levels of blood BDNF after treatment but not with physical exercise, psychotherapy, or direct current stimulation. Moreover, the rapid-acting antidepressant ketamine has presented an early increase in blood BDNF concentration. Although evidence has pointed to increased levels of BDNF after antidepressant therapy, several factors, such as heterogeneous results, low sample size, publication bias, and different BDNF measurements (serum or plasma), pose a challenge in the interpretation of the relation between peripheral blood BDNF and MDD. These potential gaps in the literature have not been properly addressed in previous narrative reviews. In this review, current evidence regarding BDNF function, genetics and epigenetics, expression, and results from clinical trials is summarized, putting the literature into a translational perspective on MDD. In general, blood BDNF cannot be recommended for use as a biomarker in clinical practice. Moreover, future studies should expand the evidence with larger samples, use the serum or serum: whole blood concentration of BDNF as a more accurate measure of peripheral BDNF, and compare its change upon different treatment modalities of MDD.

Abstract Background The Ruff Figural Fluency Test (RFFT; a pencil and paper test) and the CogState (a computerized cognitive test battery) are well-validated and suitable tests to evaluate cognitive functioning in large observational studies at the population level. The LifeLines Cohort Study includes the RFFT as baseline measurement and incorporated the CogState as replacement for the RFFT at follow-up. It is unknown how these two tests relate to each other. Therefore, the aim of this study is to examine the correlation between the RFFT and the CogState and the impact of demographic characteristics on this association. Methods A subcohort of the LifeLines Cohort Study, a large population based cohort study, participated in this study. Correlations between the RFFT and six subtasks of the CogState were examined. Subgroup analyses were performed to investigate the influence of age, education, and gender on the results. With sensitivity analyses we investigated the influence of computer experience and (physical) impairments. Results A total of 509 participants (mean age (SD): 53 years (14.6); range 18–87 years) participated in this study. All correlations between the RFFT and the CogState were statistically significant (except for the correlation between the RFFT error ratio and the CogState One Back Task), ranging from -0.39 to 0.28. Stratifying the analyses for age, education, and gender did not substantially affect our conclusions. Sensitivity analyses showed no substantial influence of level of computer experience or (physical) impairments. Conclusions Correlations found in the present study were only weak to moderate, indicating that cognitive functioning measured by the RFFT does not measure the same components of cognitive functioning as six subtasks of the CogState. Computerized testing such as the CogState may be very well suited for large cohort studies to assess cognitive functioning in the general population and to identify cognitive changes as early as possible, as it is a less time- and labor intensive tool.

Background and Objectives. In the proposed symptom network approach to psychopathology, psychiatric disorders are assumed to result from the (causal) interplay between symptoms. By implementing this approach we explored whether individual feedback on symptom dynamics complements current categorical classification and treatment. The aim of this proof-of-principle case-study was to explore the feasibility, acceptability and usability of this transdiagnostic approach. Methods. A female patient, aged 67, suffering from treatment resistant anxious and depressive symptoms was treated in our tertiary outpatient clinic for old age psychiatry. She participated in ecological momentary assessments (EMA), which in-volved intensive repeated measurements of mood and context-related items during two weeks. Visualizations of the interplay between the items were provided by network graphs and were discussed with the patient. Results. Network graphs were discussed with the patient. For example, it was hypothesized and discussed with the patient that feeling relaxed increased physical activity, causing physical discomfort in the following hours. Physical discomfort caused stress as its symptoms resembled her feared somatic anxiety symptoms. This increased the patient’s insight that stress, expressed as somatic symptoms, played a central role in her panic disorder. This started a dialogue on how to cope with stress caused by somatic (anxiety) symptoms and provided a rationale for the patient to start an interoceptive exposure intervention she had repeatedly refused before. Limitations. The observed symptom dynamics may not be generalizable to any other random two weeks. Conclusions. Personalized diagnosis of psychopathology incorporating complex symptom dynamics is feasible and a promising addition to current categorical diagnostic systems and could guide intervention selection. This merits further exploration.

Hoewel onderzoek uitwijst dat multimorbiditeit bij ouderen eerder regel dan uitzondering is, ontbreken exacte cijfers over de combinatie van psychiatrische en somatische aandoeningen, zogenaamde psychiatrisch-somatische multimorbiditeit [1].

Benzodiazepinen worden frequent langdurig voorgeschreven voor de behandeling van angst en slaapproblemen, ondanks verschillende richtlijnen hiermee terughoudend te zijn. Deze richtlijnen zijn gebaseerd op de balans tussen de effectiviteit op langere termijn en de bijwerkingen (verslaving, anterograde amnesie en verhoogd risico op (onge)vallen en mortaliteit). De verslavende eigenschappen van benzodiazepinen blijken ook op te treden bij gebruik van laag-therapeutische doseringen. Hoewel aanvankelijk de aandacht uitging naar het optreden van ontwenningsverschijnselen bij staken, is de laatste decennia meer en meer aandacht gekomen voor de psychologische aspecten van deze verslaving. Recentelijk werd in dierexperimenteel onderzoek het effect van benzodiazepinegebruik op het beloningssysteem in de hersenen aangetoond. Wanneer langdurig benzodiazepinegebruik als probleem wordt onderkend door arts en patiënt blijken verschillende behandelmodaliteiten effectief. Eén op de vier langdurig gebruikers kan op eigen kracht stoppen na goede psycho-educatie en aanmoediging. Twee op de drie kunnen stoppen met behulp van systematische dosisreductie onder begeleiding van een arts of psycholoog. In geval van een onderliggende slaap- of angststoornis, verdient het aanbeveling deze laatste behandeling aan te vullen met cognitieve gedragstherapie. In tegenstelling tot wat vaak gedacht wordt, blijken ook de oudste ouderen goed te kunnen profiteren van deze behandelingen.

Background: General anxiety and depressive symptoms following a myocardial infarction are associated with a worse cardiac prognosis. However, the contribution of specific aspects of anxiety within this context remains unclear., Aims: To evaluate the independent prognostic association of cardiac anxiety with cardiac outcome after myocardial infarction., Method: We administered the Cardiac Anxiety Questionnaire (CAQ) during hospital admission (baseline, n = 193) and 4 months (n = 147/193) after discharge. CAQ subscale scores reflect fear, attention, avoidance and safety-seeking behaviour. Study end-point was a major adverse cardiac event (MACE): readmission for ischemic cardiac disease or all-cause mortality. In Cox regression analysis, we adjusted for age, cardiac disease severity and depressive symptoms., Results: The CAQ sum score at baseline and at 4 months significantly predicted a MACE (HR baseline = 1.59, 95% CI 1.04-2.43; HR 4-months = 1.77, 95% CI 1.04-3.02) with a mean follow-up of 4.2 (s.d. = 2.0) years and 4.3 (s.d. = 1.7) years respectively. Analyses of subscale scores revealed that this effect was particularly driven by avoidance (HR baseline = 1.23, 95% CI 0.99-1.53; HR 4-months = 1.77, 95% CI 1.04-1.83)., Conclusions: Cardiac anxiety, particularly anxiety-related avoidance of exercise, is an important prognostic factor for a MACE in patients after myocardial infarction, independent of cardiac disease severity and depressive symptoms., (© The Royal College of Psychiatrists 2016.)

Objective: General anxiety in cardiac patients is associated with worsened cardiac course. An acute coronary syndrome (ACS) might evoke specific cardiac anxiety. We explored the characteristics associated with cardiac anxiety in ACS patients., Methods: We assessed cardiac anxiety in 237 patients admitted with ACS using the Cardiac Anxiety Questionnaire and gathered information on sociodemographic, psychological, and cardiac disease characteristics. Univariate, multivariate logistic, and linear regression analyses were used to determine which characteristics were associated with cardiac anxiety., Results: Cardiac anxiety was not associated with sociodemographic variables. More severe cardiac injury, as indicated by ST-elevated myocardial infarction and troponin level, was associated with less cardiac anxiety. Psychological variables (depressive symptoms, agoraphobic cognitions, avoidance behavior) were associated with more cardiac anxiety., Discussion: Cardiac anxiety in ACS patients is associated with more psychological distress but lower severity of cardiac injury as indicated by ST-elevated myocardial infarction and troponin level. Two explanations seem likely for this latter finding. First, anxious persons might seek help earlier, thus being diagnosed more often with minor cardiac pathology. Second, cardiac anxiety might partly be caused by diagnostic uncertainty. Future research should focus on communication strategies to reassure patients more efficiently.