Veronika van der Wardt

Antihypertensive treatment in people with dementia

BACKGROUND The range and magnitude of potential benefits and harms of antihypertensive treatment in people with dementia has not been previously established. METHODS A scoping review to identify potential domains of benefits and harms of antihypertensive therapy in people with dementia was undertaken. Systematic reviews of these domains were undertaken to examine the magnitude of the benefits or harms. RESULTS Potential outcome domains identified in the 155 papers in the scoping review were cardiovascular events, falls, fractures and syncope, depression, orthostatic hypotension, behavioral disturbances, polypharmacy risks, kidney problems, sleep problems, interactions with cholinesterase inhibitors, and pain. The systematic reviews across these domains identified relatively few studies done in people with dementia, and no convincing evidence of safety, benefit, or harm across any of them. DISCUSSION Given the lack of firm evidence of benefits or harm from antihypertensive therapy in people with dementia and the weak evidence for benefits in people over 80 years of age, the current presumption that the favorable evidence drawn from the treatment of nondemented people should be extrapolated to those with dementia is contentious. There is sufficient evidence to warrant particular caution and further research into treatment in this group of patients.

Adherence support strategies for exercise interventions in people with mild cognitive impairment and dementia: A systematic review

Exercise-based therapy may improve health status for people with Mild Cognitive Impairment (MCI) or dementia but cannot work without adherence, which has proven difficult. This review aimed to evaluate strategies to support adherence among people with MCI or Dementia and was completed in Nottingham/UK in 2017. A narrative synthesis was used to investigate the effectiveness or usefulness of adherence support strategies. Fifteen adherence support strategies were used including theoretical underpinning (programmes based on behavior change theories), individual tailoring, worksheets and exercise booklets, goal setting, phone calls or reminders, newsletters, support to overcome exercise barriers, information, adaptation periods, individual supervision, support for clinicians, group setting, music, accelerometers/pedometers and emphasis on enjoyable activities. Music was the only strategy that was investigated in a comparative design but was found to be effective only for those who were generally interested in participating in activities. A wide range of adherence support strategies are being included in exercise interventions for people with MCI or dementia, but the evidence regarding their effectiveness is limited.

The Association of Specific Executive Functions and Falls Risk in People with Mild Cognitive Impairment and Early-Stage Dementia

Background/Aims: Impairment in executive function is associated with a heightened risk for falls in people with mild cognitive impairment (MCI) and dementia. The purpose of this study was to determine which aspects of executive function are associated with falls risk. Methods: Forty-two participants with a mean age of 81.6 years and a diagnosis of MCI or mild dementia completed five different executive function tests from the computerised CANTAB test battery and a comprehensive falls risk assessment. Results: A hierarchical regression analysis showed that falls risk was significantly associated with spatial memory abilities and inhibition of a pre-potent response. Conclusion: The concept of executive function may be too general to provide meaningful results in a research or clinical context, which should focus on spatial memory and inhibition of a pre-potent response.

Withdrawal of antihypertensive medication: a systematic review

&NA; Although antihypertensive medication is usually continued indefinitely, observations during wash-out phases in hypertension trials have shown that withdrawal of antihypertensive medication might be well tolerated to do in a considerable proportion of people. A systematic review was completed to determine the proportion of people remaining normotensive for 6 months or longer after cessation of antihypertensive therapy and to investigate the safety of withdrawal. The mean proportion adjusted for sample size of people remaining below each studys threshold for hypertension treatment was 0.38 at 6 months [95% confidence interval (CI) 0.37–0.49; 912 participants], 0.40 at 1 year (95% CI 0.40–0.40; 2640 participants) and 0.26 at 2 years or longer (95% CI 0.26–0.27; 1262 participants). Monotherapy, lower blood pressure before withdrawal and body weight were reported as predictors for successful withdrawal. Adverse events were more common in those who withdrew but were minor and included headache, joint pain, palpitations, oedema and a general feeling of being unwell. Prescribers should consider offering patients with well controlled hypertension a trial of withdrawal of antihypertensive treatment with subsequent regular blood pressure monitoring.

Attitudes of older people with mild dementia and mild cognitive impairment and their relatives about falls risk and prevention: a qualitative study

Objective To explore the perceptions of older people with mild dementia and mild cognitive impairment, and their family carers, about falling, falls risk and the acceptability of falls prevention interventions. Design Qualitative study involving thematic analysis of semi-structured interviews with patient and relative dyads. Participants and setting 20 patient/ relative dyads recruited from Memory Assessment Services and Falls Prevention Services in the United Kingdom. Results The findings are presented under four key themes: attitudes to falls, attitudes to falls prevention interventions, barriers and facilitators, and the role of relatives. Participants’ attitudes to falls interventions were varied and sometimes conflicting. Some worried about falls, but many resisted identifying themselves as potential ‘fallers’, even despite having fallen, and rejected the idea of needing the help that structured interventions signify. Participants preferred to focus on coping in the present rather than anticipating, and preparing for, an uncertain future. Falls prevention interventions were acknowledged to be valuable in principle and if required in the future but often felt to be not necessary or appropriate at present. Conclusions This study of how persons with cognitive impairment, and their relatives, view falls risk and prevention mirror findings relating to the wider population of older persons without dementia. Participants did not generally see falls prevention interventions as currently relevant to themselves. The challenge for clinicians is how to present interventions with understanding and respect for the older person’s identity. They must identify and address goals that patients and relatives value. Simplistic or paternalistic approaches will likely fail. Individualised interventions which focus on maintaining independence and preserving quality of life are more likely to be acceptable by supporting a positive self-image for patients and their relatives.

Should guidance for the use of antihypertensive medication in older people with frailty be different

The benefits of antihypertensive treatments have been established in numerous large clinical trials. Although the Hypertension in the Very Elderly Trial (HYVET) confirmed the protective effect of blood pressure medication for healthy, older individuals without dementia over 80 years of age who do not live in a care home [1], the evidence for people who are also frail and/or have comorbidities remains unclear [2]. This is reflected in hypertension guidelines. For example, the guidelines of the European Society of Hypertension and European Society of Cardiology [3] recommend reducing the systolic blood pressure in older people who have a blood pressure of 160 mmHg or above, to between 140 and 150 mmHg with the caveat of those over 80 years of age should be in good physical and mental conditions to do so. The guidelines of the National Institute of Health and Care Excellence (NICE) for Hypertension [4] advise for people under 80 years of age a target blood pressure of 140/90 mmHg and for people over 80 years of age a target blood pressure of 150/90 mmHg. Furthermore, for people over 80 years of age, co-morbidities should be taken into account when deciding on antihypertensive treatment. While this accepts that age and comorbidities should be considered when prescribing antihypertensive medication, several questions remain: is age only relevant if someone is younger or older than 80 years? Or, does the relationship between antihypertensive treatment, age and benefits continue to change? For example, a recent cross-sectional study including Polish centenarians suggested that higher blood pressure levels might be related to better health status and higher short-term survival [5]. Which co-morbidities should influence prescription decisions, and how should they be taken into account? Frailty, a condition in which the person is at increased risk of adverse health outcomes and/or dying after a destabilising event [6], might be particularly important in this context. In their recent review, Benetos et al. [2] suggested using the comprehensive geriatric assessment to evaluate the patient’s clinical and functional parameters before deciding on treatment. While this highlights the importance of tailoring treatment, the Milan Geriatrics 75+ Cohort study (Ogliari et al.), which is included in this issue, is already one step further. Their study indicated that for people who are 75 years or older and have impaired functional and cognitive statuses, the relationship between blood pressure and 10-year mortality might be U shaped with a blood pressure of 165/85 mmHg being associated with the lowest mortality risk. This suggests that the relationship between blood pressure levels and mortality depends on functional and cognitive statuses, which should be taken into account when considering target blood pressure levels. This large cohort study (n = 1587) achieved what would currently be very difficult to do using a randomised controlled study design: without exposing participants to an unknown risk of cerebroand cardiovascular events, the study investigated the relationship between blood pressure levels and mortality in a vulnerable older population over a 10-year period. Ethical motivation to not expose participants to an increased risk of cerebroand cardiovascular events was among the reasons for the short follow-up period in the randomised controlled DANTE trial, which looked at the effects of withdrawing antihypertensive treatment on cognition in people with mild cognitive impairment [7]. The results of the Milan Geriatrics 75+ Cohort study reflect the findings of the National Health and Nutrition Examination Survey [8], which indicated that walking speed might affect the association between blood pressure and mortality. Fast walkers with blood pressure levels of 140 mmHg or higher had a higher mortality risk compared with those with lower blood pressure levels; in slow walkers, no relationship was observed; and in participants who did not complete the walk test, higher blood pressure levels (≥140 mmHg) were associated with lower mortality (diastolic: HR 0.38; CI 0.23–0.62; systolic: HR 0.10; CI 0.01–0.81). Although not completing the walking test in this study had different reasons, physical limitations were the most reported one. This suggests that frailty might be another factor that should influence prescribing decisions. However, it is important to note that the results of a sub-analysis of the HYVET study using a Frailty Index based on 60 different deficits did not show a significant effect of frailty on the impact of antihypertensive medication in terms of cardiovascular events, stroke or total mortality, although the P-values for the interaction between treatment and frailty were close to the significance levels for each of the three endpoints (P= 0.73 for cardiovascular events, P = 0.52 for stroke and P = 0.61 for total mortality) [9] and the generalisability of the results is still limited due to the characteristics of their participants. Given these findings, hypertension guidelines should advise to take frailty into consideration when making treatment decisions. In addition, frequent monitoring is required for this population as the optimal blood pressure range is limited in a U-shaped relationship especially as blood pressure levels may decrease in women after the age of 70 [10]. Furthermore, considering the limited effect preventative medication might have for a person with a shorter life

P492: Systematic review into motivational strategies that support adherence to exercise for people with mild cognitive impairment (MCI) or dementia

Introduction: Physical exercise has a positive effect on cognitive functioning, mobility and activities of daily living in people with dementia (Forbes & al., 2013; Pitkala & al., 2013). Most exercise studies employ motivational strategies to support adherence to the exercise intervention but it is unclear how effective these strategies are. The purpose of this systematic literature review was to establish the range and effect of motivational strategies used in exercise studies for people with MCI and dementia. Method: Articles were identified from the following databases: CINAHL, EMBASE, MEDLINE, PsychINFO and Web of Science. Independently, a minimum of two authors assessed relevant articles based on in- and exclusion criteria. Studies using quantitative as well as qualitative methods to evaluate the effectiveness of motivational strategies were included. Results: The review analysed 28 articles that were identified to report the use of motivational strategies in exercise studies and partly evaluated their effectiveness. Employed strategies included supervision of sessions by instructors, caregivers or students, group settings, goal setting, exercise diaries, tailoring of programme, telephone calls and music. The effectiveness of strategies was only evaluated in a minority of the studies (use of group setting, goal setting and music). Discussion: Adherence to exercise intervention and continuation of the physical activity after completion of the intervention is an ongoing issue in exercise research. Given the limited evidence regarding the effectiveness of motivational strategies, tried and new strategies should be evaluated for people with MCI and dementia to ensure optimal support of physical exercise in this group.

The relationship between cognitive abilities, well-being and use of new technologies in older people

Motivation -- The purpose of this study was to explore the relationship between cognitive abilities, well-being and use of new technologies in order to support the development of systems to sustain digital engagement of older people. Research approach -- A literature review analysed scientific articles regarding the relationship between cognitive abilities, well-being and use of new technologies for older people. Findings/Design -- The results showed that cognition has a significant effect on use of new technologies, but only one study looked at the reverse relationship and did not find a clear result. The relationship between well-being and technology use needs to be clarified in further research; however, there is strong evidence that well-being affects cognitive abilities. Research limitations/Implications -- The relationship might have an interactive, reciprocal dynamic, but needs further investigation, as not all factors in this relationship have been equally well explored. Take away message -- The results highlight the need to include well-being and health into the investigation of the relationship between cognitive abilities and use of new technologies.

Anticholinergic Drug Burden Tools/Scales and Adverse Outcomes in Different Clinical Settings: A Systematic Review of Reviews

BackgroundCumulative anticholinergic exposure (anticholinergic burden) has been linked to a number of adverse outcomes. To conduct research in this area, an agreed approach to describing anticholinergic burden is needed.ObjectiveThis review set out to identify anticholinergic burden scales, to describe their rationale, the settings in which they have been used and the outcomes associated with them.MethodsA search was performed using the Healthcare Databases Advanced Search of MEDLINE, EMBASE, Cochrane, CINAHL and PsycINFO from inception to October 2016 to identify systematic reviews describing anticholinergic burden scales or tools. Abstracts and titles were reviewed to determine eligibility for review with eligible articles read in full. The final selection of reviews was critically appraised using the ROBIS tool and pre-defined data were extracted; the primary data of interest were the anticholinergic burden scales or tools used.ResultsFive reviews were identified for analysis containing a total of 62 original articles. Eighteen anticholinergic burden scales or tools were identified with variation in their derivation, content and how they quantified the anticholinergic activity of medications. The Drug Burden Index was the most commonly used scale or tool in community and database studies, while the Anticholinergic Risk Scale was used more frequently in care homes and hospital settings. The association between anticholinergic burden and clinical outcomes varied by index and study. Falls and hospitalisation were consistently found to be associated with anticholinergic burden. Mortality, delirium, physical function and cognition were not consistently associated.ConclusionsAnticholinergic burden scales vary in their rationale, use and association with outcomes. This review showed that the concept of anticholinergic burden has been variably defined and inconsistently described using a number of indices with different content and scoring. The association between adverse outcomes and anticholinergic burden varies between scores and has not been conclusively established.

Promoting activity, independence and stability in early dementia and mild cognitive impairment (PrAISED): development of an intervention for people with mild cognitive impairment and dementia:

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless, they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is an understanding of how to develop an intervention for people with mild cognitive impairment and dementia to promote their independence, stability, and physical activity. Introduction: Older adults with dementia are at a high risk of falls. Standard interventions have not been shown to be effective in this patient population potentially due to poor consideration of dementia-specific risk factors. An intervention is required that addresses the particular needs of older people with dementia in a community setting. Methods: We followed guidelines for the development of an intervention, which recommend a structured approach considering theory, evidence and practical issues. The process used 15 information sources. Data from literature reviews, clinician workshops, expert opinion meetings, patient-relative interviews, focus groups with people with dementia and clinicians, a cross-sectional survey of risk factors, a pre-post intervention study and case studies were included. Data were synthesized using triangulation to produce an intervention suitable for feasibility testing. Practical consideration of how an intervention could be delivered and implemented were considered from the outset. Results: Elements of the intervention included individually tailored, dementia-appropriate, balance, strength and dual-task exercises, functional training, and activities aimed at improving environmental access, delivered using a motivational approach to support adherence and long-term continuation of activity. We focussed on promoting safe activity rather than risk or prevention of falls. Conclusion: We used a systematic process to develop a dementia-specific intervention to promote activity and independence while reducing falls risk in older adults with mild dementia.