Dutch Ministry of Health, Welfare and Sport; Dutch Innovation Fund of Collaborative Health Insurances; and Netherlands Organisation for Health Research and Development.

The number of dementia patients is growing, and they require a variety of services, making integrated care essential for the ability to continue living in the community. Many healthcare systems in developed countries are exploring new approaches for delivering health and social care. The purpose of this study was to describe and analyse a new approach in extensive case management programmes concerned with long-term dementia care in The Netherlands. The focus is on the characteristics, and success and failure factors of these programmes.A multiple case study was conducted in eight regional dementia care provider networks in The Netherlands. Based on a literature study, a questionnaire was developed for the responsible managers and case managers of the eight case management programmes. During 16 semistructured face-to-face interviews with both respondent groups, a deeper insight into the dementia care programmes was provided. Project documentation for all the cases was studied. The eight programmes were developed independently to improve the quality and continuity of long-term dementia care. The programmes show overlap in terms of their vision, tasks of case managers, case management process and the participating partners in the local dementia care networks. Differences concern the targeted dementia patient groups as well as the background of the case managers and their position in the local dementia care provider network. Factors for success concern the expert knowledge of case managers, investment in a strong provider network and coherent conditions for effective inter-organizational cooperation to deliver integrated care. When explored, caregiver and patient satisfaction was high. Further research into the effects on client outcomes, service use and costs is recommended in order to further analyse the impact of this approach in long-term care. To facilitate implementation, with a focus on joint responsibilities of the involved care providers, policy recommendations are to develop incentives for collaborative financial contracts between insurers and providers.

Symptoms indicative of apathy are common in community-dwelling nondemented older people who are free from depression. The independent association of stroke, other cardiovascular disease, and cardiovascular risk factors with symptoms of apathy suggests a causal role of vascular factors.

Background: Apathy is a common symptom in various neuropsychiatric diseases including mild cognitive impairment (MCI) and dementia. Apathy may be associated with an increased risk of cognitive decline. The objective of this study was to investigate if apathy predicts the progression from MCI to Alzheimer’s disease (AD). Methods: The Alzheimer’s Disease Neuroimaging Initiative is a prospective multicentre cohort study. At baseline, 397 patients with MCI without major depression were included. Clinical data and the Geriatric Depression Scale at baseline were used. Apathy was defined based on the 3 apathy items of the 15-item Geriatric Depression Scale. The main outcome measure was the association of apathy with progression from MCI to AD. Results: During an average follow-up of 2.7 years (SD 1.0), 166 (41.8%) patients progressed to AD. The presence of symptoms of apathy without symptoms of depressive affect increased the risk of progression from MCI to AD (hazard ratio = 1.85, 95% CI = 1.09–3.15). Apathy in the context of symptoms of depressive affect or symptoms of depressive affect alone, without apathy, did not increase the risk of progression to AD. Conclusions: Symptoms of apathy, but not symptoms of depressive affect, increase the risk of progression from MCI to AD. Apathy in the context of symptoms of depressive affect does not increase this risk. Symptoms of apathy and depression have differential effects on cognitive decline.

Background:Over the last decade, evidence has accumulated that vascular risk factors increase the risk of Alzheimer disease (AD). So far, few randomized controlled trials have focused on lowering the vascular risk profile to prevent or postpone cognitive decline or dementia.Objective:To systematically perform a review of randomized controlled trials (RCTs) evaluating drug treatment effects for cardiovascular risk factors on the incidence of dementia or cognitive decline.Selection criteria:RCTs studying the effect of treating hypertension, dyslipidemia, hyperhomocysteinemia, obesity, or diabetes mellitus (DM) on cognitive decline or dementia, with a minimum follow-up of 1 year in elderly populations.Outcome measure:Cognitive decline or incident dementia.Main results:In the identified studies, dementia was never the primary outcome. Statins (2 studies) and intensified control of type II DM (1 study) appear to have no effect on prevention of cognitive decline. Studies on treatment of obesity are lacking, and the results of lowering homocysteine (6 studies) are inconclusive. There is some evidence of a preventive effect of antihypertensive medication (6 studies), but results are inconsistent.Conclusion:The evidence of a preventive treatment effect aimed at vascular risk factors on cognitive decline and dementia in later life is scarce and mostly based on secondary outcome parameters. Several important sources of bias such as differential dropout may importantly affect interpretation of trial results.

Apathy, but not depression, is a strong, independent risk factor for incident CVD. It may be a marker of underlying vascular disease. By its nature, apathy may cause non-adherence to a healthy lifestyle, diminished activities, and possibly even withdrawal from clinical care aimed at improving vascular risk profiles.

BackgroundCardiovascular prevention programmes are increasingly being offered to older people. To achieve the proposed benefits, adherence is crucial. Understanding the reasons for adherence and non-adherence can improve preventive care.AimTo gain insight into what motivates older people living in the community to partake in a cardiovascular prevention programme, and reasons for subsequent continuation or withdrawal.Design and settingQualitative study of current and former participants of the ongoing ≥6 year PreDIVA (prevention of dementia by intensive vascular care) trial in primary care practices in suburban areas in the Netherlands.MethodSemi-structured interviews were conducted with a purposive sample of 15 participants (aged 76–82 years). Interviews were audiorecorded and analysed by two independent researchers using a thematic approach. Participants were asked about their motivation for participating in the programme, along with the facilitators and barriers to continue doing so.ResultsResponders reported that regular check-ups offered a feeling of safety, control, or being looked after, and were an important motivator for participation. For successful continuation, a personal relationship with the nurse and a coaching approach were both essential; the lack of these, along with frequent changes of nursing staff, were considered to be barriers. Participants considered general preventive advice unnecessary or patronising, but practical support was appreciated.ConclusionTo successfully engage older people in long-term, preventive consultations, the approach of the healthcare provider is crucial. Key elements are to offer regular check-ups, use a coaching approach and to build a personal relationship with the patient.

D rug-eluting stents became commercially available in 2002 in Europe and Canada and in 2003 in the United States 1 and are now widely used in the treatment of coronary artery disease. Restenosis of the target lesion has been the "Achilles heel" of percutaneous coronary interventions (PCIs), with 15%-40% of patients in randomized controlled trials (RCTs) who received bare-metal stents needing repeat revascularization within 6 months. 2 Numerous RCTs 3-6 and meta-analyses 7 have shown that the use of drug-eluting stents reduces this risk by an estimated 83%. Given their comparable short-term safety profiles, drugeluting stents have been seen as an attractive clinical alternative to bare-metal stents. However, no differences in deaths or myocardial infarctions have been seen between study groups receiving either type of stent. 7 Furthermore, the absolute reductions in the rate of repeat revascularization observed with drug-eluting stents may be overestimated, owing to protocoldriven angiographic follow-up in RCTs. 8,9 Nevertheless, the clinical benefits of fewer repeat revascularizations with drugeluting stents and improved quality of life, even if ephemeral, are enticing.Because drug-eluting stents are considerably more expensive than bare-metal stents, with an estimated world market of $6 billion annually, 10 cost-effectiveness analyses may help decision-makers assess the value of this additional investment. Although many cost-effectiveness studies have been carried out, they have arrived at different conclusions despite using a relatively constant measure of the efficacy of drugeluting stents. By systematically reviewing all published costeffectiveness analyses, we attempt to understand the determinants of the different conclusions. MethodsWe performed an extensive literature search for all Englishlanguage cost-effectiveness studies published between Jan. 1, 2000, and July 31, 2006, that assessed the impact of costs of drug-eluting stents compared with bare-metal stents on a health care system. We decided not to distinguish between the different models of drug-eluting stents because, although sirolimus-eluting stents appear to be more clinically effective than paclitaxel-eluting ones, 11 both are extensively used in clinical practice and because the prices of drug-eluting stents