D.J.H. Deeg

Changes over a decade in end-of-life care and transfers during the last 3 months of life: A repeated survey among proxies of deceased older people

Background: In the ageing population, older people are living longer with chronic diseases. Especially in the last year of life, this can result in an increased need for (complex) end-of-life care. Aim: To study potential changes in received end-of-life care and transfers by older people during the last 3 months of life between 2000 and 2010. Design: A repeated survey in 2000 and 2010. Participants: Data were collected from a sample of proxies of deceased sample members of the Longitudinal Aging Study Amsterdam in 2000 (n = 270; response = 79%) and 2010 (n = 168; response = 59%). Results: Compared to 2000, in 2010, older people had a significantly lower functional ability 3 months before death. Over the 10-year period, people were significantly less likely to receive no care (12% vs 39%) and more likely to receive formal home care (45% vs 15%). Older people aged over 80 years, females, and those in the 2010 sample were more likely to receive formal home and institutional care (formal home care – age > 80 years, odds ratio: 3.7, male odds ratio: 0.74, 2010 – odds ratio: 6.9; institutional care – age > 80 years, odds ratio: 11.6, male odds ratio: 0.34, 2010 – odds ratio: 2.5) than informal or no care. Regardless of the study year, older people receiving informal home care were more likely to die in hospital (odds ratio: 2.3). Conclusion: Two scenarios of care in the last 3 months of life seem to arise: staying at home as long as possible with a higher chance of hospital death or living in a residential or nursing home, reducing the chance of hospital death.

Preferences and Actual Treatment of Older Adults at the End of Life. A Mortality Follow‐Back Study

To compare actual treatments with preferences for starting or forgoing treatment of older adults at the end of life.

Peak expiratory flow rate shows a gender-specific association with vitamin D deficiency

CONTEXT To our knowledge, no previous studies examined the longitudinal relationship between vitamin D status and pulmonary function in a population-based sample of older persons. OBJECTIVE Our objective was to examine the cross-sectional as well as the longitudinal relationship between vitamin D status and peak expiratory flow rate (PEFR) in a representative sample of the Dutch older population. DESIGN, SETTING, AND PARTICIPANTS Participants included men and women in the Longitudinal Aging Study Amsterdam, an ongoing cohort study in older people. MAIN OUTCOME MEASURE PEFR was measured using the mini-Wright peak flow meter. RESULTS Men with serum 25-hydroxyvitamin D (25-OHD) levels below 10 ng/ml (25 nmol/liter) had a significantly lower PEFR in the cross-sectional analyses, and men with serum 25-OHD levels below 20 ng/ml (50 nmol/liter) had a significantly lower PEFR in the longitudinal analyses as compared with men with serum 25-OHD levels above 30 ng/ml (75 nmol/liter) (cross-sectional: β = -47.0, P = 0.01 for serum 25-OHD <10 ng/ml; longitudinal: β = -45.0, P < 0.01 for serum 25-OHD <10 ng/ml; and β = -20.2, P = 0.03 for serum 25-OHD = 10-20 ng/ml in the fully adjusted models). Physical performance (β = -32.5, P = 0.08 for serum 25-OHD <10 ng/ml) and grip strength (β = -40.0, P = 0.03 for serum 25-OHD <10 ng/ml) partly mediated the cross-sectional associations but not the longitudinal associations. In women, statistically significant associations between 25-OHD and PEFR were observed in the cross-sectional analyses after adjustment for age and season of blood collection but not in the fully adjusted models or in the longitudinal analyses. CONCLUSIONS A strong relationship between serum 25-OHD and PEFR was observed in older men, both in the cross-sectional as well as longitudinal analyses, but not in older women. The association in men could partly be explained by physical performance and muscle strength.

Do employed and not employed 55 to 64-year-olds' memory complaints relate to memory performance? A longitudinal cohort study

BACKGROUND Whether middle-aged individuals are capable of employment continuation may be limited by poor memory. Subjective memory complaints may be used to identify those at risk of poor memory. Research questions, therefore, were (i) are prevalent memory complaints associated with relevantly poor memory performance and decline in 55 to 64-year-olds; (ii) are incident memory complaints associated with relevant memory decline; and (iii) do these associations differ between employed and not employed individuals? METHODS Participants of the Longitudinal Aging Study Amsterdam (LASA) were examined. Data were weighted by sex, age and region. To examine the association of prevalent memory complaints with relevantly poor learning ability (n=903) and delayed recall (n=897; both assessed with the Auditory Verbal Learning Test), subnormal (≤ mean-1 SD) and impaired (≤ mean-1.5 SD) memory performance were defined. To examine the association of prevalent and incident memory complaints with relevant decline after 3 years in learning ability (n=774 and 611, respectively) and delayed recall (n=768 and 603, respectively), above normal (≤ mean-1 SD) and clinically relevant (≤ mean-1.5 SD) memory decline were investigated. Logistic regression analyses were applied. RESULTS Adjusted for gender, education and age, individuals with memory complaints more often had impaired delayed recall and clinically relevant decline in learning ability. Incident memory complaints were borderline significantly associated with clinically relevant decline in learning in continuously employed individuals (paid job ≥ 1 h weekly), but not in continuously not employed individuals. CONCLUSION Memory complaints may identify 55 to 64-year-olds at risk of memory impairment and decline. Our results provide hypotheses about the association between memory complaints and decline in employed 55 to 64-year-olds.

The Burden of ADHD in Older Adults A Qualitative Study

Objective: To explore how ADHD may have affected the lives of older adults who meet the diagnostic criteria of ADHD, but are unaware of their diagnosis. Our second aim was to examine whether the reported symptoms change over the life span. Method: A qualitative study was conducted. Seventeen Dutch older people (>65 years) diagnosed in this study with ADHD participated in in-depth interviews. Data were analyzed according to techniques of thematic approach. Results: Seven themes emerged from the analyses. Four themes correspond to ADHD symptoms: “being active,” “being impulsive,” “attention problems,” and “mental restlessness.” In addition, the themes “low self-esteem,” “overstepping boundaries,” and “feeling misunderstood” emerged. The impact of ADHD symptoms seems to have declined with age. Conclusion: ADHD has a negative impact on late life, and older adults with the disorder may benefit from treatment. Moreover, this study’s findings call for early detection and treatment of ADHD in children and adults.

How do general end-of-life treatment goals and values relate to specific treatment preferences? A population-based study

Background: There is a lack of research on the relationship between general end-of-life goals and values and preferences for specific life-sustaining treatments. Aim: To examine agreement between Dutch older people’s general end-of-life goals and specific life-sustaining treatment preferences. Design: Participants identified general end-of-life goals in an interview and preferences for four life-sustaining treatments in hypothetical cancer and dementia scenarios in a separate questionnaire. Agreement between general goals and specific treatment preferences was calculated. Setting/participants: In total, 1818 older people from 11 representative Dutch municipalities participated in the study. Results: In total, 1168 (response rate 73%) answered questions on general end-of-life and specific treatment preferences. Agreement between a desire to live as long as possible, irrespective of health problems, and a preference for life-sustaining treatments ranged from 51% to 76% in cancer and 41% to 60% in dementia scenarios, depending on the treatment. Agreement between a desire for a shorter life, if without major health problems, and a preference to forgo treatments ranged from 61% to 79% in cancer and 75% to 88% in dementia scenarios. Conclusion: For a sizable minority of participants, specific treatment preferences did not agree with their general end-of-life goals. The more frequent desire to forgo treatments in case of dementia than cancer suggests that physical deterioration is more acceptable than cognitive decline. The findings underline the importance of discussing general care goals, different end-of-life scenarios and the risks and burdens of treatments to frame discussions of more specific treatment preferences.

Within-Person Pain Variability and Mental Health in Older Adults With Osteoarthritis: An Analysis Across 6 European Cohorts

Pain is a key symptom of osteoarthritis (OA) and has been linked to poor mental health. Pain fluctuates over time within individuals, but a paucity of studies have considered day-to-day fluctuations of joint pain in relation to affective symptoms in older persons with OA. This study investigated the relationship of pain severity as well as within-person pain variability with anxiety and depression symptoms in 832 older adults with OA who participated in the European Project on OSteoArthritis (EPOSA): a 6-country cohort study. Affective symptoms were examined with the Hospital Anxiety and Depression Scale, pain severity was assessed with the Western Ontario and McMaster Universities OA Index and the Australian/Canadian Hand Osteoarthritis Index, and intraindividual pain variability was measured using pain calendars assessed at baseline, 6, and 12 to 18 months. Age-stratified multiple linear regression analyses adjusted for relevant confounders showed that more pain was associated with more affective symptoms in older-old participants (74.1-85 years). Moreover, older-old participants experienced fewer symptoms of anxiety (ratio = .85, 95% confidence interval [CI], .77-.94), depression (ratio = .90, 95% CI, .82-.98), and total affective symptoms (ratio = .87, 95% CI, .79-.94) if their pain fluctuated more. No such association was evident in younger-old participants (65-74.0 years). These findings imply that stable pain levels are more detrimental to mental health than fluctuating pain levels in older persons. PERSPECTIVE This study showed that more severe and stable joint pain levels were associated with anxiety and depressive symptoms in older persons with OA. These findings emphasize the importance of measuring pain in OA at multiple time points, because joint pain fluctuations may be an indicator for the presence of affective symptoms.

P-21 Older dutch people’s self-reported advance euthanasia directive completion before and after the enactment of the euthanasia law: A time trend study (1998–2011)

Background In the Netherlands, advance euthanasia directives (AED) are used to request euthanasia under specific circumstances. Although representative of patient wishes, they are not legally binding. Examining AED completion before and after the implementation of the 2002 Dutch euthanasia law can provide some insight on its influence. Aim To describe self-reported AED completion among representative samples of Dutch older people in 1998, 2005, 2008 and 2011 and to analyse associations between personal characteristics and AED completion. Methods Participants reported their AED completion in face-to-face interviews. AED prevalence was described and associated factors analysed with multivariable logistic regression using generalised estimating equations. Results AED completion of 2576 older people was recorded. Prevalence was 6.8%, 4.3%, 6.4% and 6.2%, in 1998, 2005, 2008 and 2011 respectively. The odds of completion were significantly lower in 2005 compared with 1998, although there were no significant differences in 2008 and 2011 compared with 1998. Completion was associated with increasing age, female gender, higher education and income, and negatively associated with being Catholic or Protestant. Health factors had no influence on AED completion. Discussion/conclusion Following the enactment of the 2002 Dutch euthanasia law, there was a slight decrease in AED completion which, overall, remained low. Legal recognition did not, therefore, lead to their increased use and may even have been associated with their decline in the first instance. The lack of association between AED completion and health factors indicates that older people with a range of health statuses completed AEDs, not just those with serious illness.

Ongezonde leefstijl in de loop van het leven: samenhang met lichamelijke achteruitgang op oudere leeftijd

Unhealthy lifestyles during the life course: association with physical decline in late lifeThis study aimed to examine the association between unhealthy lifestyle in young age, midlife and/or old age and physical decline in old age, and to examine the association between chronic exposure to an unhealthy lifestyle throughout life and physical decline in old age. The study sample included 1297 respondents of the Longitudinal Aging Study Amsterdam (LASA). Lifestyle in old age (55-85 y) was assessed at baseline, while lifestyle in young age (around 25 y) and midlife (around 40 y) were assessed retrospectively. Lifestyle factors included physical activity, body mass index (BMI), number of alcohol drinks per week and smoking. Physical decline was calculated as change in physical performance score between baseline and six-year follow-up. Of the lifestyle factors present in old age, a BMI of 25-29 vs. BMI <25 kg/m2 (odds ratio (OR) 1.6; 95% confidence interval (CI) 1.1-2.2) and a BMI of =30 vs. BMI <25 kg/m2 (OR 1.8; 95% CI 1.2-2.7) were associated with physical decline in old age. Being physically inactive in old age was not significantly associated with an increased risk of physical decline, however, being physically inactive both in midlife and in old age increased the odds of physical decline in old age to 1.6 (95% CI 1.1-2.4) as compared to respondents who were physically inactive in midlife and physically active in old age. Being overweight in both age periods was associated with an OR of 1.5 (95% CI 1.1-2.2). These data suggest that overweight in old age, and chronic exposure to physical inactivity or overweight throughout life increases the risk of physical decline in old age. Therefore, physical activity and prevention of overweight at all ages should be stimulated to prevent physical decline in old age.Ongezonde leefstijl en lichamelijke achteruitgang : samenvattingHet doel van deze studie was de samenhang te onderzoeken tussen ongezonde leefstijl op jonge, middelbare, en/of oudere leeftijd en lichamelijke achteruitgang op oudere leeftijd en tussen chronische blootsteling aan een ongezonde leefstijl in de loop van het leven, en lichamelijke achteruitgang op oudere leeftijd. De steekproef bestond uit 1297 respondenten van de Longitudinal Aging Study Amsterdam (LASA). Leefstijl op oudere leeftijd (55-85 jaar) werd gemeten op baseline en op jonge (circa 25 jaar) en middelbare (circa 40 jaar) leeftijd retrospectief nagevraagd en bestond uit lichamelijke activiteit, body mass index (BMI), het aantal alcoholische consumpties per week en roken. Lichamelijke achteruitgang werd berekend als het verschil in de score op lichamelijke prestatietesten tussen baseline en 6-jaar follow-up. Op oudere leeftijd was een BMI tussen 25-29 versus BMI<25 kg/m2 (Odds ratio (OR) 1,6; 95% betrouwbaarheidsinterval (BI) 1,1 – 2,2) en een BMI =30 versus BMI <25 kg/m2 (OR 1,8; 95% BI 1,2 - 2,7) geassocieerd met lichamelijke achteruitgang op oudere leeftijd. Lichamelijke inactiviteit op oudere leeftijd was niet significant gerelateerd aan lichamelijke achteruitgang, terwijl lichamelijke inactiviteit op zowel middelbare als oudere leeftijd wel het risico op lichamelijke achteruitgang op oudere leeftijd verhoogde (OR 1,6; 95% BI 1,1 – 2,4) vergeleken met respondenten die lichamelijk inactief waren op middelbare leeftijd maar wel actief op oudere leeftijd. Het hebben van overgewicht in beide leeftijdsperioden verhoogde het risico (OR 1,5; 95% BI 1,1 – 2,2). Deze gegevens suggereren dat overgewicht op oudere leeftijd en chronische blootstelling aan lichamelijke inactiviteit of overgewicht in de loop van het leven het risico op lichamelijke achteruitgang op oudere leeftijd verhoogt. Het lijkt daarom van belang om lichaamsbeweging en de preventie van overgewicht op alle leeftijden te stimuleren ter voorkoming van lichamelijke achteruitgang op oudere leeftijd.