Modifiable Risk Factors for Accelerated Decline in Processing Speed: Results from Three Dutch Population Cohorts

BACKGROUND

Several lifestyle, cardiovascular and psychosocial factors are associated with risk of cognitive decline and dementia. We studied the independent associations of a broad set of modifiable risk factors with decline in processing speed in three large population-based cohorts with up to 23 years of follow-up.

METHODS

We used data of 9,666 participants from the Doetinchem Cohort Study, the Longitudinal Aging Study Amsterdam, and the Maastricht Aging Study. Decline in processing speed was measured with the letter digit substitution task or the alphabet coding task and modeled using quadratic latent growth curves. Associations of modifiable risk factors with level and rate of decline in processing speed were investigated by estimating associations with level of processing speed at different centering ages.

RESULTS

Latent growth curves showed that decline in processing speed accelerated with age. Smoking, not drinking alcohol and depressive symptoms were associated with a lower level of processing speed in all cohorts. In two of the cohorts, more physical activity, drinking more than two glasses of alcohol per day, higher BMI and diabetes were associated with a lower level of processing speed. Depressive symptoms and diabetes were also associated with faster decline in processing speed.

CONCLUSION

Several modifiable risk factors are associated with the level of processing speed in older age, while few are also related to the rate of decline.

Previous fracture and subsequent fracture risk: a meta-analysis to update FRAX

A large international meta-analysis using primary data from 64 cohorts has quantified the increased risk of fracture associated with a previous history of fracture for future use in FRAX.

INTRODUCTION

The aim of this study was to quantify the fracture risk associated with a prior fracture on an international basis and to explore the relationship of this risk with age, sex, time since baseline and bone mineral density (BMD).

METHODS

We studied 665,971 men and 1,438,535 women from 64 cohorts in 32 countries followed for a total of 19.5 million person-years. The effect of a prior history of fracture on the risk of any clinical fracture, any osteoporotic fracture, major osteoporotic fracture, and hip fracture alone was examined using an extended Poisson model in each cohort. Covariates examined were age, sex, BMD, and duration of follow-up. The results of the different studies were merged by using the weighted β-coefficients.

RESULTS

A previous fracture history, compared with individuals without a prior fracture, was associated with a significantly increased risk of any clinical fracture (hazard ratio, HR = 1.88; 95% CI = 1.72-2.07). The risk ratio was similar for the outcome of osteoporotic fracture (HR = 1.87; 95% CI = 1.69-2.07), major osteoporotic fracture (HR = 1.83; 95% CI = 1.63-2.06), or for hip fracture (HR = 1.82; 95% CI = 1.62-2.06). There was no significant difference in risk ratio between men and women. Subsequent fracture risk was marginally downward adjusted when account was taken of BMD. Low BMD explained a minority of the risk for any clinical fracture (14%), osteoporotic fracture (17%), and for hip fracture (33%). The risk ratio for all fracture outcomes related to prior fracture decreased significantly with adjustment for age and time since baseline examination.

CONCLUSION

A previous history of fracture confers an increased risk of fracture of substantial importance beyond that explained by BMD. The effect is similar in men and women. Its quantitation on an international basis permits the more accurate use of this risk factor in case finding strategies.

Update of the fracture risk prediction tool FRAX: a systematic review of potential cohorts and analysis plan

We describe the collection of cohorts together with the analysis plan for an update of the fracture risk prediction tool FRAX with respect to current and novel risk factors. The resource comprises 2,138,428 participants with a follow-up of approximately 20 million person-years and 116,117 documented incident major osteoporotic fractures.

INTRODUCTION

The availability of the fracture risk assessment tool FRAX® has substantially enhanced the targeting of treatment to those at high risk of fracture with FRAX now incorporated into more than 100 clinical osteoporosis guidelines worldwide. The aim of this study is to determine whether the current algorithms can be further optimised with respect to current and novel risk factors.

METHODS

A computerised literature search was performed in PubMed from inception until May 17, 2019, to identify eligible cohorts for updating the FRAX coefficients. Additionally, we searched the abstracts of conference proceedings of the American Society for Bone and Mineral Research, European Calcified Tissue Society and World Congress of Osteoporosis. Prospective cohort studies with data on baseline clinical risk factors and incident fractures were eligible.

RESULTS

Of the 836 records retrieved, 53 were selected for full-text assessment after screening on title and abstract. Twelve cohorts were deemed eligible and of these, 4 novel cohorts were identified. These cohorts, together with 60 previously identified cohorts, will provide the resource for constructing an updated version of FRAX comprising 2,138,428 participants with a follow-up of approximately 20 million person-years and 116,117 documented incident major osteoporotic fractures. For each known and candidate risk factor, multivariate hazard functions for hip fracture, major osteoporotic fracture and death will be tested using extended Poisson regression. Sex- and/or ethnicity-specific differences in the weights of the risk factors will be investigated. After meta-analyses of the cohort-specific beta coefficients for each risk factor, models comprising 10-year probability of hip and major osteoporotic fracture, with or without femoral neck bone mineral density, will be computed.

CONCLUSIONS

These assembled cohorts and described models will provide the framework for an updated FRAX tool enabling enhanced assessment of fracture risk (PROSPERO (CRD42021227266)).

Exploring the conceptual framework and measurement model of intrinsic capacity defined by the World Health Organization: A scoping review

WHO has defined intrinsic capacity (IC) as the composite of all physical and mental capacities of an individual covering five subdomains: cognition, locomotion, sensory, vitality, and psychological. Despite this well accepted definition, the conceptual and measurement model of IC remains unclear, which hampers a standardized operationalization of the construct. We performed a scoping review to give a comprehensive overview of the extent to which the current literature of IC addresses and assumes the conceptual framework and measurement model of IC as reflective or formative. For inclusion, we considered all types of articles that were published in peer-reviewed journals except for protocol articles. A systematic search of 6 databases from different disciplines led to the inclusion of 31 papers. We found inconsistency and gaps in the descriptions of IC. Most of the papers did not define the measurement model. In the conceptual background and validation articles, we identified descriptions of both reflective and formative measurement models while in empirical studies applying IC measurements the underlying assumptions remained mainly unclear. Defining a measurement model is not merely a theoretical matter but influences the operationalization and validation processes of the construct. This study raised questions about the most fundamental features of the IC construct and discusses whether IC should be considered as an underlying latent trait of all capacities (reflective construct) or an aggregate summary measure of the subdomain capacities (formative construct).

Aversive response to uncertainty as a mediator for the effect of a mindfulness intervention on symptoms of anxiety

THEORETICAL BACKGROUND

Intolerance of uncertainty plays a central role in anxiety and research suggests that it's an important treatment target. Investigating response to uncertainty using other dimensions than self-report, such as physiological responses, can further the effort to understand the role of uncertainty in anxiety more fully. Mindfulness interventions have become increasingly interesting in their application to anxiety, as they foster acceptance of unpleasant aspects of experience. The aims of the study were to examine whether a mindfulness intervention reduced response to uncertainty and anxiety symptoms, and to examine the associations between intolerance of uncertainty, physiological response to uncertainty, mindfulness and anxiety.

METHODS

Participants were 117 students who completed a two-week mindfulness or audiobook control intervention. At pre- and post-intervention assessments, measures of anxiety, mindfulness, and intolerance of uncertainty were completed and a threat-of-shock task assessing startle responding to unpredictable shock was administered.

RESULTS

Findings showed a significant effect of the intervention for social anxiety symptoms. Furthermore, intolerance of uncertainty mediated the effect of the intervention on symptoms for social anxiety and worry. No such effects were found for physiological response to uncertainty.

CONCLUSION

The study adds to the understanding of the role of response to uncertainty in anxiety as well as to its mechanistic role in the context of mindfulness practice. Implications and possible explanations for the non-significant main effects of the intervention on anxiety symptoms and physiological response to uncertainty are discussed.

Impact of the COVID-19-pandemic on patients with gynecological malignancies undergoing surgery: A Dutch population-based study using data from the 'Dutch Gynecological Oncology Audit'

OBJECTIVE

The COVID-19-pandemic caused drastic healthcare changes worldwide. To date, the impact of these changes on gynecological cancer healthcare is relatively unknown. This study aimed to assess the impact of the COVID-19-pandemic on surgical gynecological-oncology healthcare.

METHODS

This population-based cohort study included all surgical procedures with curative intent for gynecological malignancies, registered in the Dutch Gynecological Oncology Audit, in 2018-2020. Four periods were identified based on COVID-19 hospital admission rates: 'Pre-COVID-19', 'First wave', 'Interim period', and 'Second wave'. Surgical volume, perioperative care processes, and postoperative outcomes from 2020 were compared with 2018-2019.

RESULTS

A total of 11,488 surgical procedures were analyzed. For cervical cancer, surgical volume decreased by 17.2% in 2020 compared to 2018-2019 (mean 2018-2019: n = 542.5, 2020: n = 449). At nadir (interim period), only 51% of the expected cervical cancer procedures were performed. For ovarian, vulvar, and endometrial cancer, volumes remained stable. Patients with advanced-stage ovarian cancer more frequently received neoadjuvant chemotherapy in 2020 compared to 2018-2019 (67.7% (n = 432) vs. 61.8% (n = 783), p = 0.011). Median time to first treatment was significantly shorter in all four malignancies in 2020. For vulvar and endometrial cancer, the length of hospital stay was significantly shorter in 2020. No significant differences in complicated course and 30-day-mortality were observed.

CONCLUSIONS

The COVID-19-pandemic impacted surgical gynecological-oncology healthcare: in 2020, surgical volume for cervical cancer dropped considerably, waiting time was significantly shorter for all malignancies, while neoadjuvant chemotherapy administration for advanced-stage ovarian cancer increased. The safety of perioperative healthcare was not negatively impacted by the pandemic, as complications and 30-day-mortality remained stable.

Land use mix and physical activity in middle-aged and older adults: a longitudinal study examining changes in land use mix in two Dutch cohorts

Background

With urbanization and aging increasing in coming decades, societies face the challenge of keeping aging populations active. Land use mix (LUM) has been associated with cycling and walking, but whether changes in LUM relate to changes in cycling/walking is less known.

Objectives

Our objective was to study the effect of LUM on cycling/walking in two Dutch aging cohorts using data with 10 years of follow-up.

Methods

Data from 1183 respondents from the Health and Living Conditions of the Population of Eindhoven and Surroundings (GLOBE) study and 918 respondents from the Longitudinal Aging Study Amsterdam (LASA) were linked to LUM in 1000-m sausage network buffers at three time-points. Cycling/walking outcomes were harmonized to include average minutes spent cycling/walking per week. Data was pooled and limited to respondents that did not relocate between follow-up waves. Associations between LUM and cycling/walking were estimated using a Random Effects Within-Between (REWB) model that allows for the estimation of both within and between effects. Sensitivity analyses were performed on smaller (500-m) and larger (1600-m) buffers.

Results

We found evidence of between-individual associations of LUM in 1000-m buffers and walking (β: 11.10, 95% CI: 0.08; 21.12), but no evidence of within-associations in 1000-m buffers. Sensitivity analyses using 500-m buffers showed similar between-associations, but negative within-associations (β: -35.67, 95% CI: − 68.85; − 2.49). We did not find evidence of between-individual associations of LUM in any buffer size and cycling, but did find evidence of negative within-associations between LUM in 1600-m buffers and cycling (β: -7.49, 95% CI: − 14.31; − 0.66).

Discussion

Our study found evidence of positive associations between LUM and average walking time, but also some evidence of negative associations between a change in LUM and cycling/walking. LUM appears to be related to cycling/walking, but the effect of changes in LUM on cycling/walking is unclear.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01083-1.

Model-based Prediction of Critical Illness in Hospitalized Patients with COVID-19

Background The prognosis of hospitalized patients with severe coronavirus disease 2019 (COVID-19) is difficult to predict, and the capacity of intensive care units was a limiting factor during the peak of the pandemic and is generally dependent on a country's clinical resources. Purpose To determine the value of chest radiographic findings together with patient history and laboratory markers at admission to predict critical illness in hospitalized patients with COVID-19. Materials and Methods In this retrospective study, which included patients from March 7, 2020, to April 24, 2020, a consecutive cohort of hospitalized patients with real-time reverse transcription polymerase chain reaction-confirmed COVID-19 from two large Dutch community hospitals was identified. After univariable analysis, a risk model to predict critical illness (ie, death and/or intensive care unit admission with invasive ventilation) was developed, using multivariable logistic regression including clinical, chest radiographic, and laboratory findings. Distribution and severity of lung involvement were visually assessed by using an eight-point scale (chest radiography score). Internal validation was performed by using bootstrapping. Performance is presented as an area under the receiver operating characteristic curve. Decision curve analysis was performed, and a risk calculator was derived. Results The cohort included 356 hospitalized patients (mean age, 69 years ± 12 [standard deviation]; 237 men) of whom 168 (47%) developed critical illness. The final risk model's variables included sex, chronic obstructive lung disease, symptom duration, neutrophil count, C-reactive protein level, lactate dehydrogenase level, distribution of lung disease, and chest radiography score at hospital presentation. The area under the receiver operating characteristic curve of the model was 0.77 (95% CI: 0.72, 0.81; P < .001). A risk calculator was derived for individual risk assessment: Dutch COVID-19 risk model. At an example threshold of 0.70, 71 of 356 patients would be predicted to develop critical illness, of which 59 (83%) would be true-positive results. Conclusion A risk model based on chest radiographic and laboratory findings obtained at admission was predictive of critical illness in hospitalized patients with coronavirus disease 2019. This risk calculator might be useful for triage of patients to the limited number of intensive care unit beds or facilities. © RSNA, 2020 Online supplemental material is available for this article.

The Application of the Concept of Resilience in Aging Research and Older Adult Care: A Focus Group Study

Introduction: Research incorporating resilience, a concept featuring a positive outcome despite some type of stressor, has the potential to identify possibilities for promotion of the well-being of older people. This study aims to gain insight into the value and potential applications of resilience in both research and care practice from the perspective of researchers and care professionals. Specifically, the value of two scientific approaches, the a priori (i.e., based on a priori definition of a stressor and outcome) and dynamical systems approaches (i.e., based on mathematically modeled patterns in the real-time response to perturbations), was explored. Methods: Focus groups were performed to explore the thoughts of academic researchers from different disciplines in the fields of aging and care and care professionals on the application of the concept of resilience, including the a priori and dynamical systems approaches. Analysis of these focus groups was based on the framework method. Results: Five focus groups were held with a total of nine researchers from different disciplines (e.g., epidemiology, sociology) and 15 older adult care professionals from different professions (e.g., elderly care physician, physiotherapist). The participants described resilience as a concept with value for both aging research and care through its positive connotation and comprehensiveness. Continued research was thought to play an important role in clearing up some of the existing ambiguity surrounding resilience. The importance of resilience in the context of both high- and low-intensity stressors was underscored. The a priori and dynamical systems approaches were considered to have their specific advantages and disadvantages on both conceptual and feasibility levels. Therefore, the use of both approaches, side by side and in combination, was suggested. Conclusion: This qualitative exploration among researchers and care professionals confirms that the concept of resilience, including the a priori and dynamical systems approaches, is valuable. However, more work is necessary before can be delivered on the potential of resilience in aging research and older adult care practice. Greater conceptual and operational clarity can be achieved through more qualitative studies on the concept that take the perspective of older people into account and through empirical studies that work with both approaches simultaneously and/or in combination.

Metabolic syndrome detection with biomarkers in childhood cancer survivors

PURPOSE

Augmented survival of childhood nephroblastoma and neuroblastoma has increased long-term side effects such as metabolic syndrome (MetS). Risk stratification is difficult after abdominal radiation because waist circumference underestimates adiposity. We aimed to develop a strategy for determining MetS in irradiated survivors using an integrated biomarker profile and vascular ultrasonography.

METHODS

The NCEP-ATPIII MetS-components, 14 additional serum biomarkers and 9 vascular measurements were assessed in a single-centre cohort of childhood nephroblastoma (n = 67) and neuroblastoma (n = 36) survivors and controls (n = 61). Multivariable regression models were used to study treatment effects. Principal component analysis (PCA) was used to study all biomarkers in a combined analysis, to identify patterns and correlations.

RESULTS

After 27.5 years of follow-up, MetS occurred more often in survivors (14%) than controls (3%). Abdominal radiotherapy and nephrectomy, to a lesser extent, were associated with MetS and separate components and with several biomarker abnormalities. PCA of biomarkers revealed a pattern on PC1 from favourable lipid markers (HDL-cholesterol, adiponectin) towards unfavourable markers (triglycerides, LDL-cholesterol, apoB, uric acid). Abdominal radiotherapy was associated with the unfavourable biomarker profile (β = 1.45, P = 0.001). Vascular measurements were not of added diagnostic value.

CONCLUSIONS

Long-term childhood nephro- and neuroblastoma survivors frequently develop MetS. Additional assessment of biomarkers identified in PCA - adiponectin, LDL, apoB, and uric acid - may be used especially in abdominally irradiated survivors, to classify MetS as alternative for waist circumference. Vascular ultrasonography was not of added value.

Associations of neighbourhood sociodemographic characteristics with depressive and anxiety symptoms in older age: Results from a 5-wave study over 15 years

We examined the long-term association between objective neighbourhood sociodemographic characteristics (index of socioeconomic position (SEP), average income, percent low-income earners, average house price, percent immigrants and urban density) with depressive and anxiety symptoms, covering five 3-year waves of the Longitudinal Aging Study Amsterdam (n = 3,772). Multi-level regression models assessed each neighbourhood-level characteristic separately, adjusting for individual-level covariates. A higher percentage of immigrants and higher urban density, but not other neighbourhood characteristics, were significantly associated with depressive and anxiety symptoms over time in models adjusted for individual SEP. Results of time interaction models indicated that the associations were stable over the 15-year period.

Do older individuals who are diagnosed with cancer have worse physical performance prior to diagnosis compared to matched controls? A longitudinal cohort study

Background

Impaired physical performance is highly prevalent in older cancer patients and is associated with cancer-related outcomes such as mortality and chemotherapy-related toxicity. Physical performance might already decline prior to the cancer diagnosis due to undiagnosed disease. This study aimed to assess whether the physical performance of community-dwelling individuals prior to cancer diagnosis is worse compared to matched controls who are not diagnosed with cancer.

Methods

The study sample was selected from the Longitudinal Aging Study Amsterdam, a longitudinal study on a nationally representative sample of the Dutch older population. Physical performance of initially cancer-free individuals aged 55–84 years who were diagnosed with cancer during 10 or 20 years of follow-up was compared to the physical performance of controls who were not diagnosed with cancer. For controls, the physical performance measurements of the cycle with a median age closest to the cancer group were used. The time interval between physical performance measurements and the report of cancer was 2 to 4 years. Groups were compared using logistic and linear regression analysis.

Results

The study sample included 1735 individuals with a median age of 68.7 [interquartile range 63.3–76.4] years. During follow-up, 414 (23.9%) individuals were diagnosed with cancer. Handgrip strength, gait speed, chair stand ability, chair stand test time and ability to put on and take off a cardigan did not differ between groups. Individuals prior to cancer diagnosis were more likely to complete the tandem balance test.

Conclusions

Physical performance of individuals 2 to 4 years prior to report of cancer diagnosis is not lower compared to controls. This suggests that physical performance may not be influenced by cancer before diagnosis.

Combination of Pulmonary Embolism Rule-out Criteria and YEARS Algorithm in a European Cohort of Patients with Suspected Pulmonary Embolism

Background Both the YEARS algorithm and the pulmonary embolism (PE) rule-out criteria (PERC) were created to exclude PE with limited diagnostic tests. A diagnostic strategy combining both scores might save additional computed tomography pulmonary angiography (CTPA) scans, but they have never been evaluated in conjunction.

Aim The aim of this study was to determine the safety and efficiency of combining YEARS and PERC in a single diagnostic strategy for suspected PE.

Methods The PERC rule was assessed in 1,316 consecutive patients with suspected PE who were managed according to YEARS. We calculated the absolute difference (with 95% confidence interval [CI]) in failure rate and the number of ‘saved’ CTPAs for the scenario that PE would have been ruled out without CTPA in the absence of all PERC items.

Results Using the YEARS algorithm, PE was diagnosed in 189 patients (14%), 680 patients (52%) were managed without CTPA and the 3-month rate of venous thromboembolism in patients in whom PE was ruled out was 0.44% (95% CI: 0.19–1.0). Only 6 of 154 patients (3.9%; 95% CI: 1.4–8.2) with no YEARS items who were referred for CTPA would have been PERC negative, of whom none were diagnosed with PE at baseline or during follow-up (0%; 95% CI: 0–64). Applying PERC before YEARS in all patients would have led to a failure rate of 1.42% (95% CI: 0.87–2.3%), 0.98% (95% CI: 0.17–1.9) more than shown in patients managed by YEARS.

Conclusion Combining YEARS with PERC would have yielded only a modest improvement of efficiency in patients without a YEARS item and an unacceptable failure rate in patients with ≥ 1 YEARS item.

MPO-ANCA associated vasculitis with mononeuritis multiplex following influenza vaccination

Background

Although influenza vaccines are generally safe and effective, a variety of autoimmune phenomena have been reported after vaccination over the past years, such as Guillain–Barre syndrome, rheumatoid arthritis, pemphigus vulgaris, psoriasis, giant cell arteritis and anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV).

Case report

We describe the case of a 67-year old man who presented with a myeloperoxidase-ANCA associated vasculitis with renal involvement and mononeuritis multiplex after seasonal influenza vaccination. He was initially treated with intravenous cyclophosphamide and high-dose prednisolone followed by maintenance treatment consisting of azathioprine and prednisolone.

Conclusion

We hypothesize that seasonal influenza vaccination triggered a systemic immune response in a susceptible patient to develop AAV with renal involvement and vasculitic neuropathy. In general, seasonal influenza vaccinations are considered to be safe, however, clinicians should be aware of this rare phenomenon.

How to determine an impaired health status in COPD: Results from a population-based study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with a significantly impaired health status and lost work productivity across all degrees of airflow limitation. The current study investigated whether an impaired health status is better represented by the recommended COPD Assessment Test (CAT) cut-point of 10 points, or the 95th percentile of the CAT score in a non-COPD population. Additionally, the impact of COPD on health status in a Dutch population, after stratification for work status, was measured.

METHODS

Demographics, clinical characteristics, post-bronchodilator spirometry, and CAT were assessed in subjects from the Longitudinal Aging Study Amsterdam (LASA), a large Dutch population-based study. Normative values for the CAT score were described by percentiles using the mean, standard deviation, median and range.

RESULTS

In total, 810 COPD and non-COPD subjects (50.4% male, mean age 60.5 ±; 2.9 years) were analysed. Significant differences were observed in CAT scores between non-COPD and COPD subjects (6.7 ±; 5.2 vs. 9.5 ±; 5.9, p < 0.001 respectively). The proportion of COPD subjects with an impaired health status differed between applying the CAT ≥ 10 cut-point (50.0%) and applying the 95th percentile of CAT in non-COPD subjects (> 18 cut-point; 7.6%). Higher CAT scores were seen in working COPD patients compared with working non-COPD subjects (9.3 ±; 5.2 vs. 6.0 ±; 4.6, p < 0.001).

CONCLUSION

We suggest a CAT cut-point of > 18 points to indicate an impaired health status in COPD. This would imply an adaptation of the current GOLD classification of the disease.

Longitudinal associations between late-life depression dimensions and cognitive functioning: a cross-domain latent growth curve analysis

BACKGROUND

Cognitive impairment and depression often co-occur in older adults, but it is not clear whether depression is a risk factor for cognitive decline, a psychological reaction to cognitive decline, or whether changes in depressive symptoms correlate with changes in cognitive performance over time. The co-morbid manifestation of depression and cognitive impairment may reflect either a causal effect or a common cause, depending on the specific symptoms experienced and the cognitive functions affected.

METHOD

The study sample comprised 1506 community-dwelling older adults aged ⩾65 years from the Longitudinal Aging Study Amsterdam (LASA). We conducted cross-domain latent growth curve analyses to examine longitudinal associations between late-life depression dimensions (i.e. depressed affect, positive affect, and somatic symptoms) and specific domains of cognitive functioning (i.e. processing speed, inductive reasoning, immediate recall, and delayed recall).

RESULTS

Poorer delayed recall performance at baseline predicted a steeper increase in depressed affect over time. Steeper decline in processing speed correlated with a steeper increase in somatic symptoms of depression over time.

CONCLUSIONS

Our findings suggest a prospective association between memory function and depressed affect, whereby older adults may experience an increase in depressed affect in reaction to poor memory function. Somatic symptoms of depression increased concurrently with declining processing speed, which may reflect common neurodegenerative processes. Our findings do not support the hypothesis that depression symptoms may be a risk factor for cognitive decline in the general population. These findings have potential implications for the treatment of late-life depression and for the prognosis of cognitive outcomes.

The long-term outcome of subthreshold depression in later life

BACKGROUND

Subthreshold depression (SUBD) in later life is common and important as prodromal state and prominent risk factor in the development of major depressive disorder (MDD). Indicated prevention can reduce the incidence of MDD among people with SUBD substantially, but needs to be targeted to those that are truly at risk of developing MDD.

METHOD

N = 341 eligible participants with SUBD were included from the first (1992/1993), second (1995/1996) and third (1998/1999) cycle from the Longitudinal Aging Study Amsterdam (LASA) by using a two-stage screening design. LASA is an ongoing prospective cohort study in The Netherlands among the older population (55-85 years). At baseline (1992/1993) N = 3107 participants were interviewed and follow-up cycles were conducted every 3 years until 2008/2009, resulting in maximal 17 years of observational period. The proportion of people that developed MDD, remained SUBD, or recovered from SUBD was measured and Cox proportional regression analyses were performed to investigate 29 putative predictors of MDD and recovery from SUBD.

RESULTS

N = 153 (44.9%) recovered from SUBD, N = 138 (40.5%) remained chronically SUBD, and N = 50 (14.7%) developed MDD (incidence rate 15.1/1000 person-years). Women, high neuroticism, more chronic diseases, high body mass index, smoking and less social support predicted conversion to MDD. Men, low neuroticism and absence of pain predicted recovery from SUBD.

CONCLUSIONS

Although older people with SUBD are clearly at risk of developing MDD, the majority did not, even after a long and thorough follow-up. Given the risk factors that were uncovered, targeting and prevention of MDD in those at very high risk is feasible.

The association of fatigue, comorbidity burden, disease activity, disability and gross domestic product in patients with rheumatoid arthritis. Results from 34 countries participating in the Quest-RA program

OBJECTIVES

The aim is to assess the prevalence of comorbidities and to further analyse to which degree fatigue can be explained by comorbidity burden, disease activity, disability and gross domestic product (GDP) in patients with rheumatoid arthritis (RA).

METHODS

Nine thousands eight hundred seventy-four patients from 34 countries, 16 with high GDP (>24.000 US dollars [USD] per capita) and 18 low-GDP countries (<24.000 USD) participated in the Quantitative Standard monitoring of Patients with RA (QUEST-RA) study. The prevalence of 31 comorbid conditions, fatigue (0-10 cm visual analogue scale [VAS] [10=worst]), disease activity in 28 joints (DAS28), and physical disability (Health Assessment Questionnaire score [HAQ]) were assessed. Univariate and multivariate linear regression analyses were performed to assess the association between fatigue and comorbidities, disease activity, disability and GDP.

RESULTS

Overall, patients reported a median of 2 comorbid conditions of which hypertension (31.5%), osteoporosis (17.6%), osteoarthritis (15.5%) and hyperlipidaemia (14.2%) were the most prevalent. The majority of comorbidities were more common in high-GDP countries. The median fatigue score was 4.4 (4.8 in low-GDP countries and 3.8 in high-GDP countries, p<0.001). In low-GDP countries 25.4% of the patients had a high level of fatigue (>6.6) compared with 23.0% in high-GDP countries (p<0.001). In univariate analysis, fatigue increased with increasing number of comorbidities, disease activity and disability in both high- and low-GDP countries. In multivariate analysis of all countries, these 3 variables explained 29.4% of the variability, whereas GDP was not significant.

CONCLUSIONS

Fatigue is a widespread problem associated with high comorbidity burden, disease activity and disability regardless of GDP.

Perceived control in health care: a conceptual model based on experiences of frail older adults

Frail older adults are increasingly encouraged to be in control of their health care, in Western societies. However, little is known about how they themselves perceive control in health care. Therefore, this study aims to investigate the concept of health care-related perceived control from the viewpoint of frail older adults. A qualitative interview study was conducted following a Grounded Theory approach. Thirty-two Dutch frail older adults, aged 65 and over, participated in 20 in-depth interviews (n=20) and three focus group discussions (n=12). Data were analysed according to techniques of coding and constant comparison. From this analysis constituting factors of perceived control emerged, providing elements of a conceptual model. Perceived control reflects the feeling or belief that health care is under control, which is constituted by five, either internal or external, factors: (I) self-confidence in organising professional and/or informal care, (II) self-confidence in health management in the home setting, (III) perceived support from people in the social network, (IV) perceived support from health care professionals and organisations, and (V) perceived support from (health care) infrastructure and services. Therefore, the concept does not only consist of people's own perceived efforts, but also includes the influence of external sources. Our conceptual model points out what external factors should be taken into consideration by health care professionals and policy makers when enhancing older people's perceived control. Moreover, it can serve as the basis for the development of a measurement instrument, to enable future quantitative research on health care-related perceived control among older adults.

Randomised comparison of initial triple DMARD therapy with methotrexate monotherapy in combination with low-dose glucocorticoid bridging therapy; 1-year data of the tREACH trial

Objectives

To compare 1-year clinical efficacy of (1) initial triple disease-modifying antirheumatic drug therapy (iTDT) with initial methotrexate (MTX) monotherapy (iMM) and (2) different glucocorticoid (GC) bridging therapies: oral versus a single intramuscular injection in early rheumatoid arthritis.

Methods

In a single-blinded randomised clinical trial patients were randomised into three arms: (A) iTDT (methotrexate+sulfasalazine+hydroxychloroquine) with GCs intramuscularly; (B) iTDT with an oral GC tapering scheme and (C) MTX with oral GCs similar to B. Primary outcomes were (1) area under the curve (AUC) of Health Assessment Questionnaire (HAQ) and Disease Activity Score (DAS) and (2) the proportion of patients with radiographic progression.

Results

281 patients were randomly assigned to arms A (n=91), B (n=93) or C (n=97). The AUC DAS and HAQ were respectively −2.39 (95% CI −4.77 to −0.00) and −1.67 (95% CI −3.35 to 0.02) lower in patients receiving iTDT than in those receiving iMM. After 3 months, treatment failure occurred less often in the iTDT group, resulting in 40% fewer treatment intensifications. The difference in treatment intensifications between the arms required to maintain the predefined treatment goal remained over time. No differences were seen between the two GC bridging therapies. Respectively 21%, 24% and 23% of patients in arms A, B and C had radiographic progression after 1 year. Patients receiving iTDT had more adjustments of their medication owing to adverse events than those receiving iMM.

Conclusions

Treatment goals are attained more quickly and maintained with fewer treatment intensifications with iTDT than with iMM. However, no difference in radiographic progression is seen. Both GC bridging therapies are equally effective and, therefore, both can be used.

Trial registration number

ISRCTN26791028.