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.
Although total cerebral blood flow (tCBF) is known to be related to age, less is known regarding the associations between tCBF and the morphologic changes of the brain accompanying cerebral aging. ...The purpose of this study was to investigate whether total cerebral blood flow (tCBF) is related to white matter hyperintensity (WMH) volume and/or cerebral atrophy. Furthermore, we investigate whether tCBF should be expressed in mL/min, as was done in all previous MR studies, or in mL/100 mL/min, which yielded good results in precious SPECT, PET and perfusion MRI studies investigating regional cerebral blood flow.
Patients were included from the nested MRI sub-study of the PROSPER study. Dual fast spin echo and FLAIR images were obtained in all patients. In addition, single slice phase contrast MR angiography was used for flow measurements in the internal carotids and vertebral arteries. tCBF was expressed in both mL/min and mL/100 mL/min.
We found a significant correlation between tCBF in mL/min and both age (r = -.124; p = p<or=.001) and parenchymal volume (r = 0.430; p<or=.001). We found no association between tCBF in mL/min and %-atrophy (r = -.077; p = .103) or total WMH volume (r = -.069; p = .148). When tCBF was expressed in mL/100 mL/min the correlation between tCBF and age was no longer found (r = -.001; p = .985). Multivariate regression analyses corrected for age showed a significant correlation between tCBF in mL/100 mL/min and WMH volume (r = -.106; p = .044). No significant association between tCBF in mL/100 mL/min and %-atrophy was found.
From this study we conclude that, when evaluating tCBF alterations due to various pathologies, tCBF should in mL/100 mL/min instead of mL/min. Furthermore, changes or differences in WMH volume should be accounted for.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
To retrospectively investigate the association between changes in total cerebral blood flow and progression of total, periventricular, and deep white matter hyperintensities over time.
The ...institutional ethics review board approved the protocol for the prospective magnetic resonance (MR) imaging study, and all participants gave written informed consent. Participants also agreed to future retrospective analysis of their MR data for research purposes. In this substudy of the Prospective Study of Pravastatin in the Elderly at Risk, investigators performed a repeated MR imaging examination after an average interval of 33 months (standard deviation, 1.4) in 390 elderly men and women (ages 70-82 years at baseline) without dementia who were at high vascular risk. White matter hyperintensities were quantified with a semiautomatic method, and total cerebral blood flow was measured with a gradient-echo phase-contrast MR imaging technique. The association between total cerebral blood flow and volume of white matter hyperintensities was analyzed with logistic regression.
There was no association between baseline cerebral blood flow and prevalence of total, periventricular, or deep white matter hyperintensities at baseline MR imaging. Moreover, decline in cerebral blood flow was not associated with increase in total load of white matter hyperintensities. When the total volume of white matter hyperintensities was separated into periventricular and deep hyperintensities, for every 50 mL/min decrease in total cerebral blood flow there was a 1.32 (95% confidence interval: 1.06, 1.66; P = .015) increase in risk for developing periventricular white matter hyperintensities; there was no association, however, between decrease in total cerebral blood flow and risk of developing deep white matter hyperintensities (odds ratio, 1.00 95% confidence interval: 0.79, 1.25; P = .98).
Decline in total cerebral blood flow is associated with increase in volume of periventricular but not deep white matter hyperintensities.
Aim
To report the expectations and experiences of general practitioners and practice nurses regarding the U‐CARE programme, to gain a better understanding of the barriers and facilitators in ...providing proactive, structured care to frail older people and to determine whether implementation is feasible.
Background
Care for older patients with complex care needs in primary care is fragmented, reactive and time consuming. A structured, proactive care programme was developed to improve physical functioning and quality of life in frail older patients.
Design
An explanatory mixed‐methods study nested in a cluster‐randomized trial.
Methods
The barriers to and needs for the provision of structured, proactive care, and expectations regarding the U‐CARE programme were assessed with pre‐questionnaires sent to all participating general practitioners (n = 32) and practice nurses (n = 21) in October 2010. Postquestionnaires measured experiences with the programme after 5 months. Twelve months later, focus group meetings were conducted.
Results
Practice nurses and general practitioners reported that it was difficult to provide proactive and structured care to older patients with multi‐morbidity, different cultural backgrounds and low socioeconomic status. Barriers were a lack of time and financial compensation. Most general practitioners and practice nurses indicated that the programme added value for the coordination of care and allowed them to provide structured care.
Conclusion
This explanatory mixed‐methods study showed that general practitioners and practice nurses perceived the U‐CARE programme as feasible in general practice. A transition was made from reactive, ad hoc care towards a proactive and preventive care approach.
Ageing is associated with a decline in cerebral blood flow. Animal studies have shown that cholesterol-lowering therapy with statins might preserve cerebral blood flow (CBF). We examined the effect ...of 40 mg pravastatin on the decline in CBF and brain volume in a subset of elderly subjects participating in the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) trial.
Randomization was not stratified according to whether or not subjects participated in the MRI substudy. In 391 men (n=226) and women (n=165) aged 70 to 82 years (mean+/-SD, 75+/-3.2), we measured total CBF (in mL/min) at baseline and after a mean+/-SD follow-up of 33+/-1.4 months with a gradient-echo phase-contrast MRI technique. Total CBF was defined as the summed flows in both internal carotid and vertebral arteries. Parenchymal volume (whole brain) was segmented with the use of in-house-developed semiautomatic software.
Total CBF significantly declined in the placebo-allocated group, from 521+/-83 to 504+/-92 mL/min (P=0.0036) and in the pravastatin-allocated group from 520+/-94 to 506+/-92 mL/min (P=0.018). This decline was not significantly different between treatment groups (P=0.56). There was also a significant reduction in brain volume over time (P<0.001), which was not different between the treatment groups (P=0.47). When expressed per unit of parenchymal volume, the decline in CBF over time was no longer statistically significant.
Elderly people at risk for cerebral vascular disease had a significant decline in CBF with increasing age that was explained by a concomitant reduction in brain volume. Treatment with 40 mg pravastatin daily had no beneficial effect on total CBF.
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