Alzheimer's disease is a neurodegenerative syndrome characterized by multiple dimensions including cognitive decline, decreased daily functioning and psychiatric symptoms. This systematic review aims ...to investigate the relation between somatic comorbidity burden and progression in late-onset Alzheimer's disease (LOAD).
We searched four databases for observational studies that examined cross-sectional or longitudinal associations of cognitive or functional or neuropsychiatric outcomes with comorbidity in individuals with LOAD. From the 7966 articles identified originally, 11 studies were included in this review. The Newcastle-Ottawa quality assessment was used. The large variation in progression measures, comorbidity indexes and study designs hampered the ability to perform a meta-analysis. This review was registered with PROSPERO under DIO: 10.15124/CRD42015027046.
Nine studies indicated that comorbidity burden was associated with deterioration in at least one of the three dimensions of LOAD examined. Seven out of ten studies investigating cognition found comorbidities to be related to decreased cognitive performance. Five out of the seven studies investigating daily functioning showed an association between comorbidity burden and decreased daily functioning. Neuropsychiatric symptoms (NPS) increased with increasing comorbidity burden in two out of three studies investigating NPS. Associations were predominantly found in studies analyzing the association cross-sectionally, in a time-varying manner or across short follow-up (≤2 years). Rarely baseline comorbidity burden appeared to be associated with outcomes in studies analyzing progression over longer follow-up periods (>2 years).
This review provides evidence of an association between somatic comorbidities and multifaceted LOAD progression. Given that time-varying comorbidity burden, but much less so baseline comorbidity burden, was associated with the three dimensions prospectively, this relationship cannot be reduced to a simple cause-effect relation and is more likely to be dynamic. Therefore, both future studies and clinical practice may benefit from regarding comorbidity as a modifiable factor with a possibly fluctuating influence on LOAD.
Exercise is often proposed as a non-pharmacological intervention to delay cognitive decline in people with dementia, but evidence remains inconclusive. Previous studies suggest that combining ...physical exercise with cognitive stimulation may be more successful in this respect. Exergaming is a promising intervention in which physical exercise is combined with cognitively challenging tasks in a single session. The aim of this study was to investigate the effect of exergame training and aerobic training on cognitive functioning in older adults with dementia.
A three-armed randomized controlled trial (RCT) compared exergame training, aerobic training and an active control intervention consisting of relaxation and flexibility exercises. Individuals with dementia were randomized and individually trained three times a week during 12 weeks. Cognitive functioning was measured at baseline, after the 12-week intervention period and at 24-week follow-up by neuropsychological assessment. The domains of executive function, episodic memory, working memory and psychomotor speed were evaluated. Test scores were converted into standardized z-scores that were averaged per domain. Between-group differences were analysed with analysis of covariance.
Data from 115 people with dementia (mean (SD) age = 79.2 (6.9) years; mean (SD) MMSE score = 22.9 (3.4)) were analysed. There was a significant improvement in psychomotor speed in the aerobic and exergame groups compared to the active control group (mean difference domain score (95% CI) aerobic versus control 0.370 (0.103-0.637), p = 0.007; exergame versus control 0.326 (0.081-0.571), p = 0.009). The effect size was moderate (partial η
= 0.102). No significant differences between the intervention and control groups were found for executive functioning, episodic memory and working memory.
To our knowledge, this is the first RCT evaluating the effects of exergame training and aerobic training on cognitive functioning in people with dementia. We found that both exergame training and aerobic training improve psychomotor speed, compared to an active control group. This finding may be clinically relevant as psychomotor speed is an important predictor for functional decline. No effects were found on executive function, episodic memory and working memory.
Netherlands Trial Register, NTR5581 . Registered on 7 October 2015.
A joint editorial published simultaneously in biomedical journals across the globe calls for swift and decisive action, noting that only fundamental and equitable changes to societies worldwide will ...reverse our current trajectory.
Research highlights ▶ An outcome instrument with sound clinimetric properties to evaluate changes in frailty is needed. ▶ Frailty level is not equivalent to the sum of its’ components. ▶ Most frailty ...instruments do not include factors in multiple dimensions. ▶ For most frailty instruments only construct validity has been studied. ▶ The Frailty Index seems to be the most suitable instrument to evaluate effect of intervention. ▶ There is a need for more consistency and transparency in frailty research.
It is challenging to use shared decision-making with patients who have a chronic health condition or, especially, multimorbidity. A patient-goal-oriented approach can thus be beneficial. This study ...aims to identify and evaluate studies on the effects of interventions that support collaborative goal setting or health priority setting compared to usual care for elderly people with a chronic health condition or multimorbidity.
This systematic review was based on EPOC, PRISMA and MOOSE guidelines. Pubmed, PsychInfo, CINAHL, Web of Science, Embase and the Cochrane Central Register of Controlled Trials were searched systematically. The following eligibility criteria were applied: 1. Randomised (cluster) controlled trials, non-randomised controlled trials, controlled before-after studies, interrupted time series or repeated measures study design; 2. Single intervention directed specifically at collaborative goal setting or health priority setting or a multifactorial intervention including these elements; 3. Study population of patients with multimorbidity or at least one chronic disease (mean age ± standard deviation (SD) incl. age 65). 4. Studies reporting on outcome measures reducible to outcomes for collaborative goal setting or health priority setting.
A narrative analysis was performed. Eight articles describing five unique interventions, including four cluster randomised controlled trials and one randomised controlled trial, were identified. Four intervention studies, representing 904, 183, 387 and 1921 patients respectively, were multifactorial and showed statistically significant effects on the application of goal setting (Patient Assessment of Chronic Illness Care (PACIC) goal setting subscale), the number of advance directives or the inclusion of goals in care plans. Explicit attention for goal setting or priority setting by a professional was a common element in these multifactorial interventions. One study, which implemented a single-factor intervention on 322 patients, did not have significant effects on doctor-patient agreement. All the studies had methodological concerns in varying degrees.
Collaborative goal setting and/or priority setting can probably best be integrated in complex care interventions. Further research should determine the mix of essential elements in a multifactorial intervention to provide recommendations for daily practice. In addition, the necessity of methodological innovation and the application of mixed evaluation models must be highlighted to deal with the complexity of goal setting and/or priority setting intervention studies.
Background
Geriatricians are often confronted with unexpected health outcomes in older adults with complex multimorbidity. Aging researchers have recently called for a focus on physical resilience as ...a new approach to explaining such outcomes. Physical resilience, defined as the ability to resist functional decline or recover health following a stressor, is an emerging construct.
Methods
Based on an outline of the state‐of‐the‐art in research on the measurement of physical resilience, this article describes what tests to predict resilience can already be used in clinical practice and which innovations are to be expected soon.
Results
An older adult's recovery potential is currently predicted by static tests of physiological reserves. Although geriatric medicine typically adopts a multidisciplinary view of the patient and implicitly performs resilience management to a certain extent, clinical management of older adults can benefit from explicitly applying the dynamical concept of resilience. Two crucial leads for advancing our capacity to measure and manage the resilience of individual patients are advocated: first, performing multiple repeated measurements around a stressor can provide insight about the patient's dynamic responses to stressors; and, second, linking psychological and physiological subsystems, as proposed by network studies on resilience, can provide insight into dynamic interactions involved in a resilient response.
Conclusion
A big challenge still lies ahead in translating the dynamical concept of resilience into clinical tools and guidelines. As a first step in bridging this gap, this article outlines what opportunities clinicians and researchers can already exploit to improve prediction, understanding, and management of resilience of older adults. J Am Geriatr Soc 67:2650–2657, 2019
Combined cognitive and physical exercise interventions have potential to elicit cognitive benefits in older adults with mild cognitive impairment (MCI) or dementia. This meta-analysis aims to ...quantify the overall effect of these interventions on global cognitive functioning in older adults with MCI or dementia. Ten randomized controlled trials that applied a combined cognitive-physical intervention with cognitive function as an outcome measure were included. For each study effect sizes were computed (i.e., post-intervention standardized mean difference (SMD) scores) and pooled, using a random-effects meta-analysis. The primary analysis showed a small-to-medium positive effect of combined cognitive-physical interventions on global cognitive function in older adults with MCI or dementia (SMD95% confidence interval=0.320.17;0.47, p<0.00). A combined intervention was equally beneficial in patients with dementia (SMD=0.360.12;0.60, p<0.00) and MCI (SMD=0.390.15;0.63, p<0.05). In addition, the analysis showed a moderate-to-large positive effect after combined cognitive-physical interventions for activities of daily living (ADL) (SMD=0.650.09;1.21, p<0.01)and a small-to-medium positive effect for mood (SMD=0.270.04;0.50, p<0.01). These functional benefits emphasize the clinical relevance of combined cognitive and physical training strategies.
Rikkert's personal experiences with death in old age led him to reflect on the importance of personalized end-of-life care. As a geriatrician, he always focused on improving functional performance ...and autonomy for older individuals. However, he now realize that facilitating a good death is equally important. In his encounters with his father, father-in-law, and beloved dog, he witnessed the need for compassionate and professional assistance in ensuring a peaceful death. These experiences have made him realize the shortcomings in his training as a geriatrician, as death and dying were not adequately addressed. Moving forward, he believes it is crucial for physicians to include death in conversations and care plans, and to receive proper training in end-of-life care.