OBJECTIVE To investigate the relationship between apathy and perceived quality of life in groups both with and without depressive symptoms or cognitive impairment. METHODS We conducted a cross... Show moreOBJECTIVE To investigate the relationship between apathy and perceived quality of life in groups both with and without depressive symptoms or cognitive impairment. METHODS We conducted a cross-sectional study comparing quality of life in older persons with and without apathy in 19 Dutch general practices. Participants were 1,118 older persons aged at least 75 years without current treatment for depression and a Mini-Mental State Examination score of at least 19. Perceived quality of life was determined using Cantril's Ladder for overall quality of life, EuroQol (EQ)-5D thermometer for subjective health quality, and De Jong-Gierveld Loneliness questionnaire for perceived loneliness. Apathy was assessed with the Apathy Scale. RESULTS Of the 1,118 older persons, apathy was present in 122 (11%) of them. Overall, apathy was associated with having no work, lower level of education, presence of depressive symptoms, cognitive impairment, and decreased scores on all quality of life measures. Among the 979 (88%) older persons without depressive symptoms and cognitive impairment, apathy was present in 73 (7.5%) of them, showing similar associations as in the total population. In the 77 (7%) persons with cognitive impairment only, apathy was correlated to a lower score on the EQ-5D thermometer. However, in the 51 (5%) depressed persons without cognitive impairment, presence of apathy did not contribute to their decreased quality of life. CONCLUSION Apathy frequently occurred in community-dwelling older persons, also in the absence of depressive symptoms and cognitive impairment. In them, apathy contributed to the perception of a diminished quality of life in various aspects of daily life. Show less
Drewes, Y.M.; Koenen, J.M.; Ruijter, W. de; Dijk-van Dijk, D.D.A. van; Weele, G.M. van der; Middelkoop, B.J.C.; ... ; Gussekloo, J. 2012
BACKGROUND Preventive care traditionally aims to prevent diseases or injuries. For older people, different aims of prevention, such as maintenance of independence and wellbeing, are increasingly... Show moreBACKGROUND Preventive care traditionally aims to prevent diseases or injuries. For older people, different aims of prevention, such as maintenance of independence and wellbeing, are increasingly important. AIM To explore GPs' perspectives on preventive care for older people. DESIGN AND SETTING Qualitative study comprising six focus groups with GPs in the Netherlands. METHOD The focus-group discussions with 37 GPs were analysed using the framework analysis method. RESULTS Whether or not to implement preventive care for older people depends on the patient's individual level of vitality, as perceived by the GP. For older people with a high level of vitality, GPs confine their role to standardised disease-oriented prevention on a patient's request; when the vitality levels in older people fall, the scope of preventive care shifts from prevention of disease to prevention of functional decline. For older, vulnerable people, GPs expect most benefit from a proactive, individualised approach, enabling them to live as independently as possible. Based on these perspectives, a conceptual model for preventive care was developed, which describes GPs' different perspectives toward older people who are vulnerable and those with high levels of vitality. It focuses on five main dimensions: aim of care (prevention of disease versus prevention of functional decline), concept of care (disease model versus functional model), initiator (older persons themselves versus GP), target groups (people with requests versus specified risk groups), and content of preventive care (mainly cardiovascular risk management versus functional decline). CONCLUSION GPs' perspectives on preventive care are determined by their perception of the level of vitality of their older patients. Preventive care for older people with high levels of vitality may consist of a standardised disease-oriented approach; those who are vulnerable will need an individualised approach to prevent functional decline. Show less
Weele, G.M. van der; Waal, M.W.M. de; Hout, W.B. van den; Craen, A.J.M. de; Spinhoven, P.; Stijnen, T.; ... ; Gussekloo, J. 2012
OBJECTIVES: to determine (cost)-effectiveness of a stepped-care intervention programme among subjects ≥75 years who screened positive for depressive symptoms in general practice. DESIGN: the... Show moreOBJECTIVES: to determine (cost)-effectiveness of a stepped-care intervention programme among subjects ≥75 years who screened positive for depressive symptoms in general practice. DESIGN: the pragmatic cluster-randomised controlled trial with 12-month follow-up. SETTING: sixty-seven Dutch general practices. SUBJECTS: two hundred and thirty-nine subjects ≥75 years screened positive for untreated depressive symptoms (15-item Geriatric Depression Scale ≥5). METHODS: usual care (34 practices, 118 subjects) was compared with the stepped-care intervention (33 practices, 121 subjects) consisting of three steps: individual counselling; Coping with Depression course; and-if indicated-referral back to general practitioner to discuss further treatment. Measurements included severity of depressive symptoms [Montgomery-Åsberg Depression Rating Scale (MADRS)], quality of life, mortality and costs. RESULTS: at baseline subjects mostly were mildly/moderately depressed. At 6 months MADRS scores had improved more in the usual care than the intervention group (-2.9 versus -1.1 points, P = 0.032), but not at 12 months (-3.1 versus -4.6, P = 0.084). No significant differences were found within two separate age groups (75-79 years and ≥80 years). In intervention practices, 83% accepted referral to the stepped-care programme, and 19% accepted course participation. The control group appeared to have received more psychological care. CONCLUSIONS: among older subjects who screened positive for depressive symptoms, an offered stepped-care intervention programme was not (cost)-effective compared with usual care, possibly due to a low uptake of the course offer.Trial registration: www.controlled-trials.com/ISRCTN 71142851v. Show less
Weele, G.M. van der; Jong, R. de; Waal, M.W.M. de; Spinhoven, P.; Rooze, H.A.H.; Reis, R.; ... ; Mast, R.C. van der 2012
BACKGROUND Screening can increase detection of clinically relevant depressive symptoms, but screen-positive persons are not necessarily willing to accept a subsequent unsolicited treatment offer.... Show moreBACKGROUND Screening can increase detection of clinically relevant depressive symptoms, but screen-positive persons are not necessarily willing to accept a subsequent unsolicited treatment offer. Our objective was to explore limiting and motivating factors in accepting an offer to join a "coping with depression" course, and perceived needs among persons aged ≥75 years who screened positive for depressive symptoms in general practice. METHODS In a randomized controlled trial, in which 101 persons who had screened positive for depressive symptoms were offered a "coping with depression" course, a sample of 23 persons were interviewed, of whom five (22%) accepted the treatment offer. Interview transcripts were coded independently by two researchers. RESULTS All five individuals who accepted a place on the course felt depressed and/or lonely and had positive expectations about the course. The main reasons for declining to join the course were: not feeling depressed, or having negative thoughts about the course effect, concerns about group participation, or about being too old to change and learn new things. Although perceived needs to relieve depressive symptoms largely matched the elements of the course, most of those who had been screened were not (yet) prepared to accept an intervention offer. Many expressed the need to discuss this treatment decision with their general practitioner. CONCLUSIONS Although the unsolicited treatment offer closely matched the perceived needs of people screening positive for depressive symptoms, only those who combined feelings of being depressed or lonely with positive expectations about the offered course accepted it. Treatment should perhaps be more individually tailored to the patient's motivational stage towards change, a process in which general practitioners can play an important role. Show less
Weele, G.M. van der; Jong, R. de; Waal, M.W.M. de; Spinhoven, P.; Rooze, H.A.H.; Reis, R.; ... ; Mast, R.C. van der 2012
Many rating scales can be self-administered or interviewer-administered, and the influence of administration method on scores is unclear. We aimed to study this influence on scores of the Geriatric... Show moreMany rating scales can be self-administered or interviewer-administered, and the influence of administration method on scores is unclear. We aimed to study this influence on scores of the Geriatric Depression Scale (GDS-15), used as a screening instrument in general practice. In two general practices 376 registered patients aged 75years and older were asked to participate. Exclusion criteria were dementia and current treatment for depression. GDS-15 was administered twice within 1month: self-administered by mail, and interviewer-administered during home visits. The sequence of administering the methods was different for the two practices. We analyzed differences in total and item GDS-scores. Of 141 subjects that participated (response rate 55%) 59 were men (42%). Mean age was 81.4years (SD 4.8). When GDS-15 was self-administered, 33 subjects (23.4%) left items unanswered. There were no items unanswered when GDS-15 was interviewer-administered. On average the self-administered total GDS-scores were 0.70 points higher than interviewer-administered scores (CI95%=0.41; 0.98), with a large range of variation in the scores (limits of agreement -2.69 to 4.08). Item-item comparisons showed high percentages of agreement. Chance-corrected agreement (kappa) was moderate to fair, but three items showed only slight agreement (kappa values <0.21). In conclusion, compared to interviewer-administered scores, scores on self-administered GDS-15 were higher. The method of administration should be taken into account when interpreting scores. Show less
Weele, G.M. van der; Waal, M.W.M. de; Hout, W.B. van den; Mast, R.C. van der; Craen, A.J.M. de; Assendelft, W.J.J.; Gussekloo, J. 2011
BACKGROUND Pernicious anaemia is undeniably associated with vitamin B12 deficiency, but the association between subnormal vitamin B12 concentrations and anaemia in older people is unclear. The aim... Show moreBACKGROUND Pernicious anaemia is undeniably associated with vitamin B12 deficiency, but the association between subnormal vitamin B12 concentrations and anaemia in older people is unclear. The aim of this systematic review was to evaluate the association between subnormal vitamin B12 concentrations and anaemia in older people. METHODS Clinical queries for aetiology and treatment in bibliographic databases (PubMed [01/1949-10/2009]; EMBASE [01/1980-10/2009]) were used. Reference lists were checked for additional relevant studies. Observational studies (> or =50 participants) and randomized placebo-controlled intervention trials (RCTs) were considered. RESULTS 25 studies met the inclusion criteria. Twenty-one observational cross-sectional studies (total number of participants n = 16185) showed inconsistent results. In one longitudinal observational study, low vitamin B12 concentrations were not associated with an increased risk of anaemia (total n = 423). The 3 RCTs (total n = 210) were well-designed and showed no effect of vitamin B12 supplementation on haemoglobin concentrations during follow-up in subjects with subnormal vitamin B12 concentrations at the start of the study. Due to large clinical and methodological heterogeneity, statistical pooling of data was not performed. CONCLUSIONS Evidence of a positive association between a subnormal serum vitamin B12 concentration and anaemia in older people is limited and inconclusive. Further well-designed studies are needed to determine whether subnormal vitamin B12 is a risk factor for anaemia in older people. Show less
Background Because pragmatic trials are performed to determine if an intervention can improve current practice, they often have a control group receiving 'usual care'. The behaviour of caregivers... Show moreBackground Because pragmatic trials are performed to determine if an intervention can improve current practice, they often have a control group receiving 'usual care'. The behaviour of caregivers and patients in this control group should be influenced by the actions of researchers as little as possible. Guidelines for describing the composition and management of a usual care control group are lacking. Aim To explore the variety of approaches to the usual care concept in pragmatic trials; and evaluate the influence of the study design on the behaviour of caregivers and patients in a usual care control group. Design of study Review of 73 pragmatic trials in primary care with a usual care control group published between January 2005 and December 2009 in the British Medical Journal, the British Journal of General Practice, and Family Practice. Outcome measures were: description of the factors influencing caregiver and patients in a usual care control group related to an individual randomised design versus cluster randomisation. Results In total, 38 individually randomised trials and 35 cluster randomised trials were included. In most trials, caregivers had the freedom to treat control patients according to their own insight; in two studies, treatment options were restricted. Although possible influences on the behaviour of control caregivers and control patients were more often identified in individually randomised trials, these influences were also present in cluster randomised trials. The description of instructions and information provided to the control group was often insufficient, which made evaluation of the trials difficult. Conclusion Researchers in primary care medicine should carefully consider the design of a usual care control group, especially with regard to minimising the risk of study-induced behavioural change. It is recommended that an adequate description of the information is provided to control caregivers and control patients. A proposal is made for an extension to the CONSORT statement that requires authors to specify details of the usual care control group. Show less
