BackgroundAfter an acute infection, older persons may benefit from geriatric rehabilitation (GR).ObjectivesThis study describes the recovery trajectories of post-COVID-19 patients undergoing GR and... Show moreBackgroundAfter an acute infection, older persons may benefit from geriatric rehabilitation (GR).ObjectivesThis study describes the recovery trajectories of post-COVID-19 patients undergoing GR and explores whether frailty is associated with recovery.DesignMulticentre prospective cohort study.Setting59 GR facilities in 10 European countries.ParticipantsPost-COVID-19 patients admitted to GR between October 2020 and October 2021.MethodsPatients’ characteristics, daily functioning (Barthel index; BI), quality of life (QoL; EQ-5D-5L) and frailty (Clinical Frailty Scale; CFS) were collected at admission, discharge, 6 weeks and 6 months after discharge. We used linear mixed models to examine the trajectories of daily functioning and QoL.Results723 participants were included with a mean age of 75 (SD: 9.91) years. Most participants were pre-frail to frail (median [interquartile range] CFS 6.0 [5.0–7.0]) at admission. After admission, the BI first steeply increased from 11.31 with 2.51 (SE 0.15, P < 0.001) points per month and stabilised around 17.0 (quadratic slope: −0.26, SE 0.02, P < 0.001). Similarly, EQ-5D-5L first steeply increased from 0.569 with 0.126 points per month (SE 0.008, P < 0.001) and stabilised around 0.8 (quadratic slope: −0.014, SE 0.001, P < 0.001). Functional recovery rates were independent of frailty level at admission. QoL was lower at admission for frailer participants, but increased faster, stabilising at almost equal QoL values for frail, pre-frail and fit patients.ConclusionsPost-COVID-19 patients admitted to GR showed substantial recovery in daily functioning and QoL. Frailty at GR admission was not associated with recovery and should not be a reason to exclude patients from GR. Show less
Kock, L. de; Groot, B.; Wijmen, J. van; Lindenberg, J.; Naus, A.; Bierlaagh, D.; Abma, T. 2023
BackgroundThere is an increased interest in the role artists can play in care for older people. This momentum comes with the need to closer investigate the nature of boundary work of creative... Show moreBackgroundThere is an increased interest in the role artists can play in care for older people. This momentum comes with the need to closer investigate the nature of boundary work of creative professionals in arts and health projects.MethodsWe conducted a responsive evaluation to provide a thick description of the boundary work involved in ENCOUNTER#9, an intergenerational arts project taking place within an older person care setting.ResultsBoundary work proved to be rewarding, yet messy and unruly. Although the lead artist had carefully planned and prepared the project and gained a broad commitment, not everything went according to plan. This led to friction and all involved put effort into adjusting goals and expectations.ConclusionWe add to the conceptualisation of boundary work in arts and health by showing that it takes place on different levels: personal, relational, organisational and public. Show less
Bavelaar, L.; Visser, M.; Walshe, C.; Preston, N.; Kaasalainen, S.; Sussman, T.; ... ; Steen, J.T. van der 2023
Background the mySupport advance care planning intervention was originally developed and evaluated in Northern Ireland (UK). Family caregivers of nursing home residents with dementia received an... Show moreBackground the mySupport advance care planning intervention was originally developed and evaluated in Northern Ireland (UK). Family caregivers of nursing home residents with dementia received an educational booklet and a family care conference with a trained facilitator to discuss their relative's future care. Objectives to investigate whether upscaling the intervention adapted to local context and complemented by a question prompt list impacts family caregivers' uncertainty in decision-making and their satisfaction with care across six countries. Second, to investigate whether mySupport affects residents' hospitalisations and documented advance decisions. Design a pretest-posttest design. Setting in Canada, the Czech Republic, Ireland, Italy, the Netherlands and the UK, two nursing homes participated. Participants in total, 88 family caregivers completed baseline, intervention and follow-up assessments. Methods family caregivers' scores on the Decisional Conflict Scale and Family Perceptions of Care Scale before and after the intervention were compared with linear mixed models. The number of documented advance decisions and residents' hospitalisations was obtained via chart review or reported by nursing home staff and compared between baseline and follow-up with McNemar tests. Results family caregivers reported less decision-making uncertainty (-9.6, 95% confidence interval: -13.3, -6.0, P < 0.001) and more positive perceptions of care (+11.4, 95% confidence interval: 7.8, 15.0; P < 0.001) after the intervention. The number of advance decisions to refuse treatment was significantly higher after the intervention (21 vs 16); the number of other advance decisions or hospitalisations was unchanged. Conclusions the mySupport intervention may be impactful in countries beyond the original setting. Show less
Netzer, S.; Chocano-Bedoya, P.; Feller, M.; Janett-Pellegri, C.; Wildisen, L.; Buchi, A.E.; ... ; Rodondi, N. 2023
Background loss of skeletal muscle function, strength and mass is common in older adults, with important socioeconomic impacts. Subclinical hypothyroidism is common with increasing age and has been... Show moreBackground loss of skeletal muscle function, strength and mass is common in older adults, with important socioeconomic impacts. Subclinical hypothyroidism is common with increasing age and has been associated with reduced muscle strength. Yet, no randomized placebo-controlled trial (RCT) has investigated whether treatment of subclinical hypothyroidism affects muscle function and mass. Methods this is an ancillary study within two RCTs conducted among adults aged >= 65 years with persistent subclinical hypothyroidism (thyrotropin (TSH) 4.60-19.99 mIU/l, normal free thyroxine). Participants received daily levothyroxine with TSH-guided dose adjustment or placebo and mock titration. Primary outcome was gait speed at final visit (median 18 months). Secondary outcomes were handgrip strength at 1-year follow-up and yearly change in muscle mass. Results we included 267 participants from Switzerland and the Netherlands. Mean age was 77.5 years (range 65.1-97.1), 129 (48.3%) were women, and their mean baseline TSH was 6.36 mIU/l (standard deviation [SD] 1.9). At final visit, mean TSH was 3.8 mIU/l (SD 2.3) in the levothyroxine group and 5.1 mIU/l (SD 1.8, P < 0.05) in the placebo group. Compared to placebo, participants in the levothyroxine group had similar gait speed at final visit (adjusted between-group mean difference [MD] 0.01 m/s, 95% confidence interval [CI] -0.06 to 0.09), similar handgrip strength at one year (MD -1.22 kg, 95% CI -2.60 to 0.15) and similar yearly change in muscle mass (MD -0.15 m(2), 95% CI -0.49 to 0.18). Conclusions in this ancillary analysis of two RCTs, treatment of subclinical hypothyroidism did not affect muscle function, strength and mass in individuals 65 years and older. Show less
Objective to investigate the association between variability and loss of body weight with subsequent cognitive performance and activities of daily living in older individuals. Design cross... Show moreObjective to investigate the association between variability and loss of body weight with subsequent cognitive performance and activities of daily living in older individuals. Design cross-sectional cohort study. Setting PROspective Study of Pravastatin in the Elderly at Risk, multicentre trial with participants from Scotland, Ireland and the Netherlands. Subjects 4,309 participants without severe cognitive dysfunction (mean age 75.1 years, standard deviation (SD) = 3.3), at higher risk for cardiovascular disease (CVD). Methods body weight was measured every 3 months for 2.5 years. Weight loss was defined as an average slope across all weight measurements and as >= 5% decrease in baseline body weight during follow-up. Visit-to-visit variability was defined as the SD of weight measurements (kg) between visits. Four tests of cognitive function were examined: Stroop test, letter-digit coding test (LDCT), immediate and delayed picture-word learning tests. Two measures of daily living activities: Barthel Index (BI) and instrumental activities of daily living (IADL). All tests were examined at month 30. Results both larger body weight variability and loss of >= 5% of baseline weight were independently associated with worse scores on all cognitive tests, but minimally with BI and IADL. Compared with participants with stable weight, participants with significant weight loss performed 5.83 seconds (95% CI 3.74; 7.92) slower on the Stroop test, coded 1.72 digits less (95% CI -2.21; -1.13) on the LDCT and remembered 0.71 pictures less (95% CI -0.93; -0.48) on the delayed picture-word learning test. Conclusion in older people at higher risk for CVD, weight loss and variability are independent risk-factors for worse cognitive function. Show less
Objectives: Previous findings suggest a vascular foundation underlying apathy, but transdiagnostic and prospective evidence on vascular apathy is scarce. This study examines the association between... Show moreObjectives: Previous findings suggest a vascular foundation underlying apathy, but transdiagnostic and prospective evidence on vascular apathy is scarce. This study examines the association between vascular disease and the presence and development of apathy symptoms in the very old.Methods: Four cohorts of the Towards Understanding Longitudinal International older People Studies (TULIPS)-consortium were included in a two-staged, individual participant data meta-analysis using generalized linear mixed models, Vascular disease was defined as a history of any clinical atherosclerotic pathology (angina pectoris, myocardial infarction, intermittent claudication, transient ischemic attack, stroke or related surgeries) and was related to apathy symptoms as repeatedly measured by the Geriatric Depression Scale (GDS-3A >= 2) over a maximum of 5 years.Results: Of all 1868 participants (median age 85 years old), 53.9% had vascular disease and 44.3% experienced apathy symptoms. Participants with vascular disease had a 76% higher risk of apathy symptoms at baseline (odds ratio (OR) 1.76, 95% confidence interval (CI) 1.32-2.35), irrespective of depressive symptoms and only partially explained by stroke. Conversely, there was no association of vascular disease with the occurrence of apathy symptoms longitudinally, both in those with apathy at baseline (OR 1.00, 95% CI 0.84-1.20) and without (OR 0.96, 95% CI 0.841.09).Conclusions: Vascular disease in the very old is associated with apathy symptoms cross-sectionally, but not proven longitudinally, independent of depressive symptoms. These findings query a vascular cause underlying apathy symptoms. However, the consistency of our cross-sectional findings in direction and magnitude across the TULIPS-consortium do emphasize international relevance of the interplay of vascular factors and apathy in advanced age, which meaning needs further unravelling. Show less
The COVID-19 pandemic emphasises the importance of care for our societies, yet underscores the inferiority of relational caring practices. During this time, we studied the participatory work of... Show moreThe COVID-19 pandemic emphasises the importance of care for our societies, yet underscores the inferiority of relational caring practices. During this time, we studied the participatory work of artists working with older adults using participant observations, in-depth interviews and visual ethnography. In this article, we present a case study of one arts initiative, a theatre company engaging seniors in the Netherlands, using ethics and aesthetics of care as sensitising concepts. The findings reveal that this work can promote relational forms of care. This study makes visible how different forms of care can be identified in a participatory art project. Show less
Subclinical hypothyroidism (SCHT) is defined as a consistently elevated thyroid stimulating hormone (TSH) with a free T4 (fT4) within the reference range. This diagnosis may lead to additional... Show moreSubclinical hypothyroidism (SCHT) is defined as a consistently elevated thyroid stimulating hormone (TSH) with a free T4 (fT4) within the reference range. This diagnosis may lead to additional monitoring, levothyroxine therapy and increased patient concerns, despite lack of evidence of treatment benefit in older adults. In order to avoid this diagnosis, we evaluated the efficiency of fT4-based screening for thyroid dysfunction, in older adults in primary care and compared it with TSH-based screening. Individuals aged >65years in primary care were selected for this retrospective study when both TSH and fT4 were individually requested irrespective of the TSH value. Exclusion criteria were C-reactive protein > 10 mg/l or a history of thyroid hormone monitoring in the previous year. Screening based on fT4 instead of TSH decreased reflex testing from 23.8% to 11.2%. The positive predictive value (PPV) for clinical hypothyroidism increased from 17.3% to 52.2%. The negative predictive value was 96.1% with TSH-based screening versus 97.8% with fT4-based screening. Elevation of the TSH cutoff value from 4.2 to 6.5 mU/l resulted in a reflex test percentage of 12.5% and a PPV of 31.0%. Our results suggest that screening for thyroid dysfunction in older individuals in primary care can be improved by screening based on fT4 instead of TSH or by adjusting the TSH cutoff value. Adjustment of the screening strategy may be of interest to health policy makers because of potential cost reduction. From a patient perspective, medical concerns and unnecessary biochemical follow-up might be reduced by circumventing the diagnosis SCHT. Show less
Self-ageism has a significant negative impact on older people's ageing experiences and health outcomes. Despite ample evidence on cross-cultural ageism, studies have rarely looked into the way... Show moreSelf-ageism has a significant negative impact on older people's ageing experiences and health outcomes. Despite ample evidence on cross-cultural ageism, studies have rarely looked into the way cultural contexts affect self-ageism. In this article, we compare expressions of self-ageism and its possible predictors across four European countries based on two questionnaires in a study sample of 2,494 individuals aged 55 and older. We explore how predictors of self-ageism are moderated by cultural values in a comparative fixed-effects regression model. We empirically show that similarly to ageism, self-ageism is not present in the same way and to the same extent in every country. Moreover, the level to which cultures value hierarchy and intellectual autonomy significantly moderates the association between self-ageism and individual predictors of self-ageism. Our study adds to the small existing body of work on self-ageism by confirming empirically that certain expressions of self-ageism and individual predictors are susceptible to change in different cultural contexts. Our research results suggest that self-ageism interventions may benefit from a culturally sensitive approach and imply that more culturally diverse comparisons of self-ageism are necessary to figure out fitting ways to reduce self-ageism. Show less
Long-term care homes play an essential role within health and social care. Successful measures to support older people at home for longer have led to increased prevalence of disability, frailty and... Show moreLong-term care homes play an essential role within health and social care. Successful measures to support older people at home for longer have led to increased prevalence of disability, frailty and cognitive impairment in those who live in care homes over the last two decades. The need for care home places is projected to increase for the next two decades. Modern care homes provide care for people who are predominantly over 80, have multiple long-term conditions, take multiple medicines, are physically dependent and live with cognitive impairment. Residents do better when services recognise the contributions of staff and care home providers rather than treating residents as individual patients living in a communal setting. There is a strong case given residents' frailty, multimorbidity and disability, that care should be structured around Comprehensive Geriatric Assessment (CGA). Care should be designed to allow opportunities for multiprofessional teams to come together for CGA, particularly if healthcare professionals are based outside care homes. Good data about care homes and residents are central to efforts to deliver high quality care-in some countries, these data are collected but not collated. Collating such data is a priority. Care home staff are under-recognised and underpaid-parity of pay and opportunity with NHS staff is the bare minimum to ensure that the best are recruited and retained in the sector. During the COVID-19 pandemic, residents and relatives have frequently been left out of decisions about policies that affect them, and better consultation is needed to deliver high quality care. Show less
The sustainability of healthcare of older people in Europe is at stake. Many experts currently focus on the COVID-19 pandemic and its consequences. But there are other elements coming up that might... Show moreThe sustainability of healthcare of older people in Europe is at stake. Many experts currently focus on the COVID-19 pandemic and its consequences. But there are other elements coming up that might even have a greater impact. Healthcare systems, geriatric care and geriatric rehabilitation in particular, will face disruptive changes due to both demographic demand and a shortage of human and financial resources. This decade will be transformed by a high proportion of the older health workforce transitioning to retirement. This expertise must be retained. The brain drain of health care workers migrating from Eastern parts to Western Europe is diminishing. Discussing and deciding upon the priorities of value-based health care for older people such as equity and access is required. The acute healthcare sector in most countries focuses on fee-for-service models instead of building systemic approaches to maximise independence and autonomy of older citizens. In this commentary, we build on recent book chapters and articles on geriatric rehabililtation. Our main questions for the anniversary edition of Age and Ageing is what it is that geriatric rehabilitation could, should and must contribute in the roaring 2020s? Show less
Gordon, A.L.; Achterberg, W.P.; Delden, J.J.M. van 2022
The COVID-19 pandemic has particularly adversely affected older people with frailty and functional dependency. Essential regular contact with care staff has been evidenced as an important source of... Show moreThe COVID-19 pandemic has particularly adversely affected older people with frailty and functional dependency. Essential regular contact with care staff has been evidenced as an important source of infection for this group. Vaccinating care staff can reduce the incidence, duration and severity of infection, preventing onward transmission to older people and minimising the harm associated with discontinuity caused by staff absence. Voluntary vaccination programmes for staff are more likely to be effective when associated with information and education, community engagement and financial incentives, but programmes using all of these approaches have failed to establish consistently high vaccination rates among care staff during the pandemic. Mandatory vaccination, proposed as a solution in some countries, can increase vaccination rates. It is only ethical if a vaccine is effective and cost-effective, the risk associated with vaccinating care workers is proportionate to the risk reduction achieved through vaccination, and where all efforts to encourage voluntary vaccination have been exhausted. Even when these conditions have been met, careful attention is required to ensure that the penalties associated with conscientious objection are proportionate and to ensure that implementation is equitable in a way that does not disadvantage particular groups of staff. Show less
As the world's population continues to age over the decades ahead, medical educators and researchers in every adult medical and surgical specialty will need to 'geriatricise' their clinical science... Show moreAs the world's population continues to age over the decades ahead, medical educators and researchers in every adult medical and surgical specialty will need to 'geriatricise' their clinical science. Many have already engaged with geriatrics. Here we describe the progress that has been made and the opportunities ahead in the field of Geriatric Emergency Medicine (GEM), a field that has taken large steps in integrating holistic care. Future opportunities exist in the three domains of evidence-based medicine: including patient preferences and needs, generating scientific evidence, and improving physician knowledge and expertise. Implementation requires new innovations also in the organisation of care. Similar strategies may be useful in other fields of medicine, in making holistic care the standard for older people. Show less
Background Daily functioning is known to decline after a hip fracture, but studies of self-reported functioning before the fracture suggest this decline begins before the fracture. Objective... Show moreBackground Daily functioning is known to decline after a hip fracture, but studies of self-reported functioning before the fracture suggest this decline begins before the fracture. Objective Determine whether change in functioning in the year before a hip fracture in very old (80+) differs from change in those without a hip fracture. Design Two-stage individual patient data meta-analysis including data from the Towards Understanding Longitudinal International older People Studies (TULIPS)-consortium. Setting Four population-based longitudinal cohorts from the Netherlands, New Zealand and the UK. Subjects Participants aged 80+ years. Methods Participants were followed for 5 years, during which (instrumental) activities of daily living [(I)ADL] scores and incident hip fractures were registered at regular intervals. Z-scores of the last (I)ADL score and the change in (I)ADL in the year before a hip fracture were compared to the scores of controls, adjusted for age and sex. Results Of the 2,357 participants at baseline, the 161 who sustained a hip fracture during follow-up had a worse (I)ADL score before the fracture (0.40 standard deviations, 95% CI 0.19 to 0.61, P = 0.0002) and a larger decline in (I)ADL in the year before fracture (-0.11 standard deviations, 95% CI -0.22 to 0.004, P = 0.06) compared to those who did not sustain a hip fracture. Conclusions In the very old a decline in daily functioning already starts before a hip fracture. Therefore, a hip fracture is a sign of ongoing decline and what full recovery is should be seen in light of the pre-fracture decline. Show less
Buttgereit, T.; Palmowski, A.; Forsat, N.; Boers, M.; Witham, M.D.; Rodondi, N.; ... ; Buttgereit, F. 2021
Background: older people remain underrepresented in clinical trials, and evidence generated in younger populations cannot always be generalized to older patients.Objective: to identify key barriers... Show moreBackground: older people remain underrepresented in clinical trials, and evidence generated in younger populations cannot always be generalized to older patients.Objective: to identify key barriers and to discuss solutions to specific issues affecting recruitment and retention of older participants in clinical trials based on experience gained from six current European randomised controlled trials (RCTs) focusing on older people.Methods: a multidisciplinary group of experts including representatives of the six RCTs held two networking conferences and compiled lists of potential barriers and solutions. Every item was subsequently allocated points by each study team according to how important it was perceived to be for their RCTs.Results: the six RCTs enrolled 7,612 older patients. Key barriers to recruitment were impaired health status, comorbidities and diverse health beliefs including priorities within different cultural systems. All trials had to increase the number of recruitment sites. Other measures felt to be effective included the provision of extra time, communication training for the study staff and a re-design of patient information. Key barriers for retention included the presence of severe comorbidities and the occurrence of adverse events. Long study duration, frequent study visits and difficulties accessing the study site were also mentioned. Solutions felt to be effective included spending more time maintaining close contact with the participants, appropriate measures to show appreciation and reimbursement of travel arrangements.Conclusion: recruitment and retention of older patients in trials requires special recognition and a targeted approach. Our results provide scientifically-based practical recommendations for optimizing future studies in this population. Show less
Bogaerts, J.M.K.; Ballmoos, L.M. von; Achterberg, W.P.; Gussekloo, J.; Streit, S.; Ploeg, M.A. van der; ... ; Poortvliet, R.K.E. 2021
Background translation of the available evidence concerning primary cardiovascular prevention into clinical guidance for the heterogeneous population of older adults is challenging. With this... Show moreBackground translation of the available evidence concerning primary cardiovascular prevention into clinical guidance for the heterogeneous population of older adults is challenging. With this review, we aimed to give an overview of the thresholds and targets of antihypertensive drug therapy for older adults in currently used guidelines on primary cardiovascular prevention. Secondly, we evaluated the relationship between the advised targets and guideline characteristics, including guideline quality. Methods we systematically searched PubMed, Embase, Emcare and five guideline databases. We selected guidelines with (i) numerical thresholds for the initiation or target values of antihypertensive drug therapy in context of primary prevention (January 2008-July 2020) and (ii) specific advice concerning antihypertensive drug therapy in older adults. We extracted the recommendations and appraised the quality of included guidelines with the AGREE II instrument. Results thirty-four guidelines provided recommendations concerning antihypertensive drug therapy in older adults. Twenty advised a higher target of systolic blood pressure (SBP) for octogenarians in comparison with the general population and three advised a lower target. Over half of the guidelines (n = 18) recommended to target a SBP <150 mmHg in the oldest old, while four endorsed targets of SBP lower than 130 or 120 mmHg. Although many guidelines acknowledged frailty, only three gave specific thresholds and targets. Guideline characteristics, including methodological quality, were not related with the recommended targets. Conclusion the ongoing debate concerning targets of antihypertensive treatment in older adults, is reflected in an inconsistency of recommendations across guidelines. Recommended targets are largely set on chronological rather than biological age. Show less
Care homes enable people with advanced physical and cognitive impairment to live well with 24-h support from staff. They are a feature of care systems in most countries. They have proved pivotal to... Show moreCare homes enable people with advanced physical and cognitive impairment to live well with 24-h support from staff. They are a feature of care systems in most countries. They have proved pivotal to the coronavirus disease 2019 (COVID-19) response. We searched Age and Ageing for care-home articles published since 2015. From these we collated 42 into the Age and Ageing care-home collection. This collection draws together important papers that show how Age and Ageing is helping to shape and grow care-home research. The collection outlines the technical issues that researchers face by grouping together important feasibility trials conducted in the sector. It looks at the challenges of measuring quality of life and working with routine data in care homes. It brings together observational studies considering loneliness, functional dependency, stroke outcomes, prescribing and acute deterioration. Health services research in care homes is represented by two studies that demonstrate realist evaluation as a way to make sense of service innovations. Papers are included that consider: non-pharmacological strategies for residents with dementia, end-of-life care, sexuality and intimacy and the care-home workforce. Given the importance of the COVID-19 pandemic in care homes, all of the care home COVID-19 papers published in Age and Ageing to date are included. Finally, a group of papers that present innovative approaches to research in care homes, each of which give voice to residents and/or staff, are collated and presented as a way of moving towards a more resident and care home centred research agenda. Show less
Background: Understanding if and how pain influences activities of daily living (ADL) in dementia is essential to improving pain management and ADL functioning. This study examined the relationship... Show moreBackground: Understanding if and how pain influences activities of daily living (ADL) in dementia is essential to improving pain management and ADL functioning. This study examined the relationship between the course of pain and change in ADL functioning, both generally and regarding specific ADL functions.Methods: Participants were Dutch nursing home residents (n = 229) with advanced dementia. ADL functioning was assessed with the Katz ADL scale, and pain with the Dutch version of the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC-D). Changes of PACSLAC-D and Katz ADL scores were computed based on the difference in scores between baseline, 3-month and 6-month follow-up. Multivariate linear regression models were used to assess the relationships between change in pain score, change in total ADL score and specific ADL item scores during follow-up.Results: At baseline, residents had a median ADL score of 18 (interquartile range 13-22, range 6-24) and 48% of the residents were in pain (PACSLAC-D >= 4). Residents with pain were more ADL dependent than residents without pain. A change in pain score within the first 3 months was a significant predictor for a decline in ADL functioning over the 6-month follow-up (B = 0.10, SE = 0.05, P = 0.045), and specifically, a decline on the items 'transferring' over the 6-month follow-up and `feeding' during the first 3 months of follow-up.Conclusions: Pain is associated with ADL functioning cross-sectionally, and a change in pain score predicts a decline in ADL functioning, independent of dementia severity. Awareness of (changes in) ADL activities is clearly important and might result in both improved recognition of pain and improved pain management. Show less
