Entete 3

Monthly Archives: May 2017

Comorbidity and progression of late onset Alzheimer’s Disease: A systematic review

By Miriam L. Haaksma
and Lara R. Vilela, Alessandra Marengoni, Amaia Calderón-Larrañaga, Jeannie-Marie S. Leoutsakos, Marcel G.M. Olde Rikkert, René J.F. Melis.
Alzheimer’s disease is a neurodegenerative syndrome characterized by multiple dimensions including cognitive decline, decreased daily functioning and psychiatric symptoms. This systematic review [1] aimed to investigate the relation between somatic comorbidity burden and progression in late-onset Alzheimer’s disease (LOAD). We searched four databases for observational studies that examined cross-sectional or longitudinal associations of cognitive or functional or neuropsychiatric outcomes with comorbidity in individuals with LOAD. From the 7966 articles identified originally, 11 studies were included in this review. Nine studies indicated that comorbidity burden was associated with deterioration in at least one of the three dimensions of LOAD examined. Seven out of ten studies investigating cognition found comorbidities to be related to decreased cognitive performance. Five out of the seven studies investigating daily functioning showed an association between comorbidity burden and decreased daily functioning. Neuropsychiatric symptoms (NPS) increased with increasing comorbidity burden in two out of three studies investigating NPS. Associations were predominantly found in studies analyzing the association cross-sectionally, in a time-varying manner or across short follow-up (≤2 years). Rarely baseline comorbidity burden appeared to be associated with outcomes in studies analyzing progression over longer follow-up periods (>2 years). This review provides evidence of an association between somatic comorbidities and multifaceted LOAD progression. Given that time-varying comorbidity burden, but much less so baseline comorbidity burden, was associated with the three dimensions prospectively, this relationship cannot be reduced to a simple cause-effect relation and is more likely to be dynamic. Therefore, both future studies and clinical practice may benefit from regarding comorbidity as a modifiable factor with a possibly fluctuating influence on LOAD.

Is it possible to improve drug prescription in primary care patients with multimorbidity and polypharmacy by implementing the Ariadne principles in clinical practice?

By Alexandra Prados Torres
This is the question that Multi-PAP is trying to answer.
Multi-PAP is a coordinated multicentre project aimed at designing and measuring the effectiveness of a complex intervention in primary care for improving drug prescription in multimorbid patients compared to usual care. The intervention is based on the Ariadne principles designed by Muth et al. in 2014, and consists of two components: training of General Practitioners (GP) and GP-patient interviews.
Training of physicians has been conceived as a 4-weeks massive online open course (MOOC) designed by a multidisciplinary team with emphasis in multimorbidity, polypharmacy, medication appropriateness and adherence, and the Ariadne principles and tools for their implementation in clinical practice. During GP-patient interviews that will be conducted over a month, physicians are expected to put into practice the knowledge acquired during the training.
To measure the effectiveness of this intervention, Multi-PAP is conducting a pragmatic cluster randomized clinical trial (RCT) in primary care health centres in three regions in Spain (Aragon, Madrid and Andalusia). The unit of randomization is the family physician (N=80), and the unit of analysis is the patient. The study population is conformed by 400 patients (200 per study arm) aged 65–74 years with multimorbidity (defined as presence of 3 or more chronic diseases) and polypharmacy (defined as 5 or more drugs prescribed in ≥3 months). The intervention is based on the implementation of the Ariadne principles (GP training and GP-patient interviews) and it is compared to usual care. The main outcomes, to be measured at months 6 and 12, are: MAI score, health services use, quality of life, pharmacotherapy and adherence to treatment, and clinical and socio-demographic variables.
This project is justified by the need to provide evidence concerning interventions on primary care patients with polypharmacy and multimorbidity, conducted in the context of routine clinical practice, and involving young-old patients with significant potential for preventing negative health outcomes.
This RCT is registered in Clinicaltrials.gov (NCT02866799). Accessible at:
The full-text protocol of Multi-PAP RCT is accessible at: http://rdcu.be/rErC