Within the framework of self-determination theory, we aim to assess the effect of an educational intervention among staff in temporary care institutions in municipalities. The level of competences was increased among staff in the institutions. It is possible to plan an effective training program using self-determination theory. To deliver an effective training intervention to staff in temporary elder care institutions in municipalities. A geriatric department at a university hospital in collaboration with 6 surrounding municipalities. The training intervention was planned using self-determination theory as framework. Important elements were relation building, giving nursing staff a choice concerning themes of teaching sessions (supports autonomy) and selection of cases, supporting competence development through case-based discussions. Study design and statistical approach: before and after the intervention, an electronic questionnaire was mailed to staff at care institutions in the municipalities. The questionnaire contained questions drawn from the Basic Psychological Need Satisfaction and Frustration Scale (BPNSFS). Differences concerning competences between before and after the intervention were assessed using Wilcoxon signed-rank test. 55 persons answered the BPNSFS before and after the intervention. For all items in BPNSFS, the results after compared to before improved. However, the improvement was significant only for the sum of all items with a mean difference of 0.13, p = 0.05, and for one single item (I feel capable at what I do at work), with a mean difference of 0.15, p = 0.02. We have shown that self-determination theory has the potential to provide a theoretical framework for planning training interventions among staff in temporary elder care institutions. It is possible to measure the effect using an instrument developed within the framework of self-determination theory (BPNSFS).

Frailty is a common clinical syndrome in older adults, characterised by reduced physiological reserve and impaired homeostasis across multiple organ systems. Frailty arises from cumulative biological changes rather than chronological ageing alone. Key mechanisms include cellular damage, mitochondrial dysfunction, chronic low-grade inflammation, sarcopenia, osteoporosis, and reduced neurological reserve. This review finds that these interacting processes lead to impaired stress responses, functional decline, increased fall risk, and vulnerability to adverse health outcomes.

Abstract Background B-lines by lung ultrasound (LUS) are associated with left ventricular (LV) dysfunction and may be useful for diagnostics in resource-limited settings. Purpose To assess the incidence of LV dysfunction in the general population of the Amazon Basin and to evaluate the diagnostic potential of LUS. We defined LV dysfunction as LV ejection fraction <45% and LUS was assessed across eight chest zones. B-lines were calculated as the sum of all zones. Methods and results We conducted echocardiography and LUS in 514 individuals from a population sample in the Amazon Basin (mean age 41 years, 40% men). No patients had known heart failure, renal insufficiency or lung disease. A total of 14 individuals (3%) had LV dysfunction, corresponding to an incidence of 27.2 per 1,000 individuals. The mean number of B-lines in the general population was 0.2 (range 0 to 17 B-lines). Individuals with LV dysfunction presented with a significantly higher number of B-lines (P=0.006) and more frequently had >=3 B-lines (8% vs 2%, P=0.018) compared to those with normal LV function. Identification of >=3 B-lines yielded a sensitivity of 58% and specificity of 93% (AUC 0.72, negative predictive value 99%, positive predictive value 19%) for detecting LV dysfunction. Per 1 unit increase in B-lines, LV ejection fraction decreased by 9% (95%CI: -15% to -3%, P=0.010) and the relationship persisted to be significant after adjusting for age, sex, body mass index, heart rate and creatinine (-8%, 95%CI: -15% to -2%, P=0.016). Conclusion The incidence of LV dysfunction in the Amazon Basin was 27.2/1,000 individuals and B-lines by LUS was able to detect LV dysfunction with reasonable diagnostic accuracy. Moreover, a higher number of B-lines was associated with decreasing LV ejection fraction. Our findings indicate that LUS may supplement conventional cardiac diagnostics for assessing LV function, especially in rural environments with restricted access to imaging tools.B-lines and LV ejection fraction

Background Frailty is a major geriatric syndrome that predicts increased vulnerability to minor stressor events and adverse outcomes such as falls, fractures, disability and death. The prevalence of frailty among individuals above the age of 65 varies widely with an overall weighted prevalence of 10.7%.Objectives The purpose of this study was to examine the prevalence of prefrailty and frailty in community-dwelling older adults from the regions of Lolland-Falster, which is one of the most socioeconomically disadvantaged areas of Denmark with lower income and lower life expectancy compared with the general Danish population. Moreover, the objective was to find selected individual characteristics associated with frailty.Design An observational, cross-sectional registry-based population study with data from the regions of Lolland-Falster collected between February 2016 and February 2020.Results The study included 19 000 individuals. There were 10 154 above the age of 50 included for analysis. Prevalence of frailty in the age group of 50–64 years was 4.7% and 8.7% in the age group of 65 years and above.The study demonstrates associations between frailty and high age, female gender, low education level, low income, smoking, living alone, frequency of seeing one’s children and getting help when needed. These associations are comparable with findings from other studies.Conclusion The syndrome of frailty consists of not only physiological and medical issues but also education, life conditions such as living alone and living in poverty and how you evaluate your own health.

Older frail patients with multiple diagnoses and comprehensive medication lists are at risk of drug interaction, adverse events, and unnecessary medication. The aim of this review is to evaluate existing tools for deprescribing in older frail patients. The identified eight tools can be organised in three levels. They all contribute to the understanding and execution of deprescribing. Further studies increasing the current evidence of the deprescribing tools are needed. Further studies concerning patient barriers and clinical outcomes are needed.

The results of our nationwide nested case-control study of menopausal hormone therapy and the risk of dementia 1 align with those of the largest randomised, double blind, placebo controlled trial on the topic, the Women’s Health Initiative Memory Study (WHIMS), which reported an increased dementia rate among women aged 65 years or older randomised to menopausal hormone therapy. 2 Our study, designed to tackle limitations and biases of previous studies, consistently showed increased dementia rates across different durations and ages of hormone therapy use in a dose-response manner. 1 By design, our study cannot determine causality, as stated in the linked editorial by Kantarci and Manson. 3 Nonetheless, the evidence underlying clinicalimplicationsmustbevalidandsolid.Kantarci andMansonciteevidencehamperedbysubstantial limitationsthatarenotdiscussed. 4 -6 Kantarci and Manson cite the WHIMS of Younger Women (WHIMS-Y) as reporting no cognitive effects from hormone therapy, except potential verbal fluency impairment. 4 WHIMS-Y was, however, 3.5 times smaller than WHIMS and thus likely underpowered to detect effects of hormone therapy on dementia in this younger population. Of the placebo group, 53.2% had been users of hormone therapy, potentially causing an underestimation of risk estimates. Further, participants were unmasked to their treatment, and cognitive function was tested by telephone, different from the clinical dementia evaluation done in WHIMS. Two other referenced trials had smaller sample sizes with short follow-up and were similarly only designed to detect changes in markers of cognitive function, not clinical outcomessuchasdementia. 56 Thus,thesetrialswere unable to reach conclusions about the long term safety of menopausal hormone therapy regarding dementia risk. As

This study examines the association between use of estrogen-only therapy for perimenopausal and menopausal women and risk of dementia.

To investigate associations between dizziness, hearing loss, medication, and self-perceived health in the region of Lolland-Falster in Denmark. A cross-sectional population-based study using data from questionnaires and physical examinations between February 8th, 2016, and February 13th, 2020. Individuals aged 50 years or above in the region of Lolland-Falster were randomly invited to participate. Of 10,092 individuals (52 http://www.clinicaltrials.gov (NCT02482896).

Objective Most previous studies on advance care planning (ACP) have focused on patients with specific diseases and only a few on frail ageing individuals. We therefore decided to examine the perspective of geriatric patients on ACP. Our research questions include if, when, with whom and with which content geriatric patients wish to have ACP conversations. Design Participants were interviewed either in the hospital or in their own home. The interviewer followed a semistructured interview guide. Interviews were transcribed and analysed using the systemic text condensation method. Setting Geriatric department in a regional hospital in a rural area in Region Zealand, Denmark. Participants We included 11 geriatric patients aged above 65 who had been referred for geriatric inpatient or outpatient assessment. Participants were clinically judged by experienced geriatricians to have sufficient physical and mental capacity to take part in an interview. Results This study's main finding is that geriatric patients have varying preferences and feelings towards ACP. Some expressed concerns about ACP, especially regarding personal fear to talk about end-of-life (EOL) decisions, and whether a busy healthcare system has the resources to conduct ACP. Proper timing of ACP seemed unrelated to specific age but related to perception of health situation. The health professional involved should be well trained and a person the participant could trust. Most participants wanted family members to participate. Concerning content, participants mentioned quality of life, fear of losing their spouse, earlier experience with death, and practical concerns regarding funeral and will. Conclusion Among geriatric patients, feelings towards ACP are mixed. Even participants who were generally positive towards the concept uttered concerns about the circumstances when talking about EOL topics. Health professionals therefore should approach ACP discussions with caution. Further studies aiming to develop guidelines describing the proper way to introduce and perform ACP in this patient group are needed.

Abstract Introduction Underdetection of dementia in areas with low socioeconomic status (SES) may interfere with findings concerning associations between SES and dementia. Methods Using administrative registers we assessed the associations between age‐ and sex‐adjusted dementia incidence and neighborhood socioeconomic status (nSES) in 94 Danish municipalities. Wealth was divided into income quartiles and other nSES variables were dichotomized into high versus low according to the median. Results High population density (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.18–1.24), higher proportion of inhabitants in higher income quartiles (P for trend < .0001), and high educational level (OR 1.19, 95% CI 1.15–1.22) were associated with higher incidence of dementia. High proportion of residents above 65 years was associated with lower age‐adjusted dementia incidence (OR 0.86, 95% CI 0.84–0.89). Discussion Low nSES municipalities have a lower age‐adjusted incidence of dementia diagnosis. These findings corroborate prior concerns that a large number of dementia diagnoses may be missed in municipalities characterized by low SES.

Background: Identification of pleural effusion (PE) in dengue infection is an objective measure of plasma leakage which is useful to grade disease severity. However, no studies have investigated the prevalence of PE in dengue. Method: We searched Pubmed, Embase and Web of Science (1900-2021; Figure A) for studies reporting on PE in dengue patients (hospitalized and outpatient). We defined PE as fluid in the thoracic cavity detected by any imaging diagnostic test. The study was registered in PROSPERO (CRD42021228862). Complicated dengue was defined as hemorrhagic fever, presence of warning signs or severe dengue. Results: The search identified 1,869 studies of which 84 studies were eligible for inclusion. The studies (n=25 children, n=21 adults, n=38 mixed) involved 12,448 patients (32% complicated dengue). The overall prevalence of PE was 31% (95%CI: 28-35). In non-complicated dengue the prevalence was 16% (95%CI: 12-20), while it was 44% in complicated dengue (95%CI: 32-56). The prevalence of PE was 39% in children (95%CI: 28-50) and 23% in adults (95%CI: 18-28). USG more frequently detected PE than CXR (Figure B). Conclusion: PE was present in 1/3 of patients with dengue and children more often had PE compared to adults. USG more frequently identified PE compared to CXR. PE may serve as a useful guide in dengue case assessment and clinical management.

INTRODUCTION:People with type 2 diabetes have increased risk of dementia. Glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) are among the promising therapies for repurposing as a treatment for Alzheimer's disease; a key unanswered question is whether they reduce dementia incidence in people with type 2 diabetes. METHODS:We assessed exposure to GLP-1 RAs in patients with type 2 diabetes and subsequent diagnosis of dementia in two large data sources with long-term follow-up: pooled data from three randomized double-blind placebo-controlled cardiovascular outcome trials (15,820 patients) and a nationwide Danish registry-based cohort (120,054 patients). RESULTS:Dementia rate was lower both in patients randomized to GLP-1 RAs versus placebo (hazard ratio [HR]: 0.47 (95% confidence interval [CI]: 0.25-0.86) and in the nationwide cohort (HR: 0.89; 95% CI: 0.86-0.93 with yearly increased exposure to GLP-1 RAs). DISCUSSION:Treatment with GLP-1 RAs may provide a new opportunity to reduce the incidence of dementia in patients with type 2 diabetes.

Many medical, neurologic and psychiatric conditions as well as drugs can give chronic dizziness, and a systematic diagnostic workup is essential. Chronic vestibular syndrome is a clinical syndrome of chronic vertigo, dizziness or unsteadiness lasting months to years. There is generally a persistent unilateral or bilateral vestibular loss. Treatment depends on the aetiology, but in general, treatment with vestibular rehabilitation is effective, which is summarised in this review. Betahistin or other anti-vertigo-drugs are not indicated in the treatment of chronic vertigo.

Abstract Background Several studies have indicated that self-perception of health is related to cardiovascular disease. Despite cardiovascular disease is the leading cause of mortality in South America, the relationship between patient reported health and cardiovascular risk is sparsely explored, specifically in indigenous areas. Purpose We assessed if self-rated health is associated with cardiovascular risk factors in a remote area in South America. Methods We included participants by cluster-randomization of community health care clinics from June to December 2020. Sociodemographic variables and information on cardiovascular risk factors were collected by questionnaires and physical examination. All participants rated their present health status according to the validated EQ5D-VAS instrument, ranging from 0 (worst) to 100 (best). Results A total of 492 participants (mean age 41±15 years; 38% men) were included. The mean value of self-rated health was 80 (range 0 to 100) and the prevalence of cardiovascular risk factors were: Hypertension (19%), hypercholesterolemia (15%), smoking (37%), low intake of vegetables (defined as <3 times per week; 54%), no sport activity (62%), diabetes (6%) and obesity (24%). In logistic regression models adjusted for sex, age and socioeconomic status, higher self-rated health was significantly associated with lower risk of hypertension, hypercholesterolemia, smoking, obesity and greater vegetable intake (P<0.05; Figure 1). No association was found with sport activity or diabetes. The total number of cardiovascular risk factors increased with lower self-rated health (beta = 0.100 [0.04 to 0.15], P<0.001 per 10 decrease in self-reported health). Conclusion Self-rated health was significantly associated with a greater burden of cardiovascular risk factors and may influence ideal cardiovascular health. Future studies should assess if patient reported health status constitutes an independent risk factor for heart disease in this specific population, and studies elucidating gaps on self-perception of cardiovascular health are encouraged. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Independent Research Fund Denmark

Objectives To examine a narrative multisource feedback (MSF) instrument concerning feasibility, quality of narrative comments, perceptions of users (face validity), consequential validity, discriminating capacity and number of assessors needed. Design Qualitative text analysis supplemented by quantitative descriptive analysis. Setting Internal Medicine Departments in Zealand, Denmark. Participants 48 postgraduate trainees in internal medicine specialties, 1 clinical supervisor for each trainee and 376 feedback givers (respondents). Intervention This study examines the use of an electronic, purely narrative MSF instrument. After the MSF process, the trainee and the supervisor answered a postquestionnaire concerning their perception of the process. The authors coded the comments in the MSF reports for valence (positive or negative), specificity, relation to behaviour and whether the comment suggested a strategy for improvement. Four of the authors independently classified the MSF reports as either ‘no reasons for concern’ or ‘possibly some concern’, thereby examining discriminating capacity. Through iterative readings, the authors furthermore tried to identify how many respondents were needed in order to get a reliable impression of a trainee. Results Out of all comments coded for valence (n=1935), 89% were positive and 11% negative. Out of all coded comments (n=4684), 3.8% were suggesting ways to improve. 92% of trainees and supervisors preferred a narrative MSF to a numerical MSF, and 82% of the trainees discovered performance in need of development, but only 53% had made a specific plan for development. Kappa coefficients for inter-rater correlations between four authors were 0.7–1. There was a significant association (p<0.001) between the number of negative comments and the qualitative judgement by the four authors. It was not possible to define a specific number of respondents needed. Conclusions A purely narrative MSF contributes with educational value and experienced supervisors can discriminate between trainees’ performances based on the MSF reports.

Abstract Background Patients with acute malaria are at risk of pericarditis and may benefit from timely identification of pericardial effusion. However, diagnostic imaging tools, such as echocardiography, are not always available in malaria endemic regions. Purpose The aim of this study is to examine the diagnostic yield of pathology in electrocardiograms (ECG) to identify pericardial effusion in acute malaria. Methods We enrolled adult acute malaria patients in community healthcare clinics in a remote area in South America. All patients underwent ECG, echocardiography, and peripheral blood smears. We excluded patients on anti-malarial medication, suspected concomitant infection and pregnant women. All ECGs were examined for the following criteria: (i) PR-depression >0.5mm and/or ST-elevation 0.5–1mm (I, II, aVL, aVF, V2–6) (ii) PR-elevation >0.5mm (only aVR), (iii) ST/T-ratio >0.25 (only V6), (v) low voltage, defined as QRS amplitude <5 mm in limb leads or <10 mm in precordial leads, and (vi) Spodick's sign (all leads). A criterion was positive when present in ≥2 leads. Information on shortness of breath and/or chest pain was also collected. Pericardial effusion was diagnosed by echocardiography and had to be ≥0.5cm in width. Results We included 99 non-severe malaria patients (age 40±15 years, 55% men, median parasite density 1517/mm3, [interquartile range 528 to 6,585/mm3]) who suffered from Plasmodium vivax (n=75), falciparum (n=22 falciparum) and mixed vivax/falciparum (n=2). The ECGs showed a mean frequency of 78±16bpm, PR-interval 147±20ms, QRS 88±11ms and QT-interval 376±34ms. A total of 11 patients displayed pericardial effusion (mean width 0.9±0.3cm, n=7 vivax, n=2 falciparum, n=2 mixed). Patients with effusion were older (mean age 39 vs 53 years, P=0.003), but displayed no difference in sex, parasite density or parasite species compared to patients without pericardial effusion (P>0.05). Distribution of ECG findings and symptoms are displayed in figure 1A. PR-depression had a sensitivity and specificity for diagnosing pericardial effusion of 73% and 90%, respectively. The sensitivity and specificity for other ECG findings and clinical symptoms are displayed in Figure 1B. Conclusion ECG findings may aid in identifying pericardial effusion in acute malaria, specifically PR depression which had a diagnostic yield of 73% sensitivity and 90% specificity. Based on this, ECG in acute malaria may improve treatment and risk stratification when echocardiography is not an option. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Novo Nordisk Foundation, Independent Research Fund Denmark ECG findings in malaria patients

INTRODUCTION:Use of systemic hormone therapy has been positively associated with development of dementia. Little is known about the dose-dependent effect of vaginal estradiol on dementia risk. METHODS:We assessed associations between cumulative dose of vaginal estradiol tablets and dementia in a case-control study nested in a nationwide Danish cohort of women aged 50 to 60 years at study initiation, who did not use systemic hormone therapy. Each case was age-matched to 10 female controls. RESULTS:A total of 4574 dementia cases were matched to 45,740 controls. Cumulative use of vaginal estradiol tablets was not associated with all-cause dementia; adjusted hazard ratio 1.02 (95% confidence interval [CI] 0.89-1.18) for low dose (< 750 mcg), 1.07 (0.94-1.21) for medium dose (750-2000 mcg), and 0.93 (0.84-1.03) for high dose (> 2000 mcg). Similarly, Alzheimer's disease (AD) only was not associated with vaginal estradiol. DISCUSSION:Exposure to vaginal estradiol tablets was not associated with all-cause dementia or AD only.

AbstractBackgroundGlucagon‐like peptide 1 receptor agonists (GLP‐1 RA) have previously shown improved measures of memory and reduced phospho‐tau burden in preclinical animal models relevant to progressive cognitive impairment (Hansen. J Alzheimers Dis.2015;46:877‐88; Hansen. Brain Res.2016;1634:158‐70). Liraglutide and semaglutide are structurally similar GLP‐1 RAs associated with potent glucose‐lowering effect, body weight loss and cardiovascular benefits shown in large cardiovascular outcomes trials (CVOTs) (Marso. N Engl J Med.2016;375:311‐22; Marso. N Engl J Med.2016;375:1834‐44; Husain. N Engl J Med.2019;381:841‐51). In order to investigate the potential effects of GLP‐1 RA on dementia in a clinical setting, a post‐hoc analysis was conducted based on pooled data from three CVOTs.MethodLEADER, SUSTAIN 6 and PIONEER 6 were randomised, double‐blind, multicentre, placebo‐controlled CVOTs evaluating the cardiovascular effect of liraglutide or semaglutide vs. placebo, added to standard of care. The trials included patients with type 2 diabetes and established or high risk of cardiovascular disease. A post‐hoc analysis on pooled data from the three CVOTs was considered appropriate due to the similarities in trial design, patient population and treatment effects. Across all trials 15,820 patients with median follow‐up of 3.6 years were included in this analysis. Dementia‐related adverse events (AEs) were identified using Standardised MedDRA (version 21.1) Query for “dementia” narrow search terms. AE data collection across the trials differed in line with the regulatory requirements at the time of trial conduct. In LEADER and PIONEER 6 only serious AEs were systematically collected, while all AEs were collected in SUSTAIN 6. A time‐to‐event analysis based on the Cox proportional‐hazards model using treatment as covariate was used to estimate the hazard ratio for developing dementia.ResultAcross the three CVOTs, 15 GLP‐1 RA‐treated patients and 32 placebo‐treated patients were identified with development of dementia (Figure). Post‐hoc analysis on the pooled data showed a significant estimated hazard ratio of 0.47 [0.25; 0.86]95%CI in favour of the GLP‐1 RA treatment versus placebo.Conclusion Post‐hoc analysis based on pooled data from three double‐blinded CVOTs suggests, albeit with a low number of events, a reduced risk of dementia with liraglutide or semaglutide treatment in patients with type 2 diabetes.

Objectives Frailty is a major clinical geriatric syndrome associated with serious adverse events including functional disability, falls, hospitalisation, increased morbidity and mortality. The aim of this study was to study the associations between frailty defined as Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA-7) score ≥3 and use of healthcare resources in hospital and in the municipality as well as association between frailty and mortality.Design Register-based retrospective study.Setting The target population consists of patients aged 75 years or above who, during hospital stay, were assessed by a physiotherapist, and at discharge from hospital were prescribed further physical training in the community.Participants 973 individuals aged 75+ years were included.Outcome measures We examined associations between frailty and use of healthcare resources in hospital and in the municipality as well as the association between frailty and mortality.Results 973 individuals aged 75+ years were included. Of these, 63.9% had a PRISMA-7 score ≥3 and were thus defined as frail. Frail individuals were older compared with non-frail with mean ages of 84.6 and 80.4 years, respectively, p>0.001. Age and gender-adjusted mortality after 1 year was higher among the frail (OR 2.46, 95% CI 1.53 to 3.97). Use of healthcare services in the municipality as well as hospital admissions was significantly higher among frail individuals.Conclusions Based on these findings we consider PRISMA-7 to be useful in an in-hospital setting as a screening tool to identify frail elderly patients who may profit from further geriatric assessment during hospital stay.Trial registration number ID REG-070-2017.