The meaning of frailty according to Dutch older frail and non-frail persons

Frailty is a term often used by researchers and clinicians to describe a state in which older persons are at risk for adverse outcomes such as falls, disability, institutionalization and mortality. However, no study so far examined what frailty means to older persons. Therefore the aim of this study was to describe the meaning that older community-dwelling persons attach to frailty. Twenty-five semi-structured interviews were conducted. The interviews were analyzed using the grounded theory method. Frailty was described as being in poor health, having walking difficulties, feeling down, being anxious, having few social contacts and not being able to do the things one likes to do. Men described in more detail the physical dimension whereas women elaborated in more depth on the psychological and social component. Existing definitions of frailty should be adjusted to better reflect the meaning of frailty for older persons.     

Health profiles and profile-specific health expectancies of older women and men: The Netherlands

This study focuses on gender differences in health profiles, and examines which health profiles drive gender differences in remaining life expectancy in women and men aged 65 and over in The Netherlands. Data from the first two cycles of the Longitudinal Aging Study Amsterdam (n = 2,141 and 1,659, respectively) were used to calculate health profiles for individuals of 65-85 years. For both women and men, six profiles were found: I. cancer; II. "other" chronic diseases; III. cognitive impairment; IV. frailty or multimorbidity; V. cardiovascular diseases; and VI. good health. The further characterization of these types showed some gender differences. Remaining life expectancy for women was greater than for men in each health profile. A decomposition into health expectancies showed that both women and men could expect to live about 5 years in good health from age 66. The greatest gender differences in years spent with health problems were found for profile IV and for profile III. Their greater number of years spent in these health states have direct consequences for the type and cost of care women need.     

Do early life and contemporaneous macroconditions explain health at older ages?

This paper presents an approach that assesses the role of early life and contemporaneous macroconditions in explaining health at older ages. In particular, we investigate the role of exposure to diseases and economic conditions during infancy and childhood, as well as the effect of current health care facilities. Specific attention is paid to the impact of unobserved heterogeneity, selective attrition, and omitted relevant macrovariables. We apply our approach to self-reports on functional limitations of Dutch older individuals. The prevalence of functional limitations is found to increase in the 1990s, in part due to restricted access to hospital care.     

Life expectancies in specific health states: Results from a joint model of health status and mortality of older persons

With the trend toward aging, increases in health care expenditures are expected. Insight into (future) needs for care services requires a taxonomy of older persons' health conditions: how health status develops as people age and how these health conditions determine residual life expectancy. In this paper we provide this information for the Netherlands. We apply a flexible nonparametric method--the Grade of Membership method--to a national database and summarize the multidimensional concept of health status into a limited set of interpretable indices. We then use these indices in our panel data model for health status and mortality. The model results are used to calculate age-health profiles and expected residual lifetimes in specific health states.     

Issues of Psychoanalytic Technique With Adoptees

Treatment issues relevant to the psychoanalytic treatment of the adoptee are presented; clinical formulation is encouraged within broad ego-diagnostic parameters. The adoptee's internal cathexis of the biological mother is identified as a core dynamic and the binary transference involving the adoptee's displaced relation to a dual set of parental representations is described. A metapsychological bias, predicated upon differential perceptions of the status of self and object representations is described and related to the adoptee's treatment. Various transference/countertransference dyads are discussed, as are corresponding technical considerations.     

Applications of Bayesian statistical methodology to clinical trial design: A case study of a phase 2 trial with an interim futility assessment in patients with knee osteoarthritis

Development of new pharmacological treatments for osteoarthritis that address unmet medical needs in a competitive market place is challenging. Bayesian approaches to trial design offer advantages in defining treatment benefits by addressing clinically relevant magnitude of effects relative to comparators and in optimizing efficiency in analysis. Such advantages are illustrated by a motivating case study, a proof of concept, and dose finding study in patients with osteoarthritis. Patients with osteoarthritis were randomized to receive placebo, celecoxib, or 1 of 4 doses of galcanezumab. Primary outcome measure was change from baseline WOMAC pain after 8 weeks of treatment. Literature review of clinical trials with targeted comparator therapies quantified treatment effects versus placebo. Two success criteria were defined: one to address superiority to placebo with adequate precision and another to ensure a clinically relevant treatment effect. Trial simulations used a Bayesian dose response and longitudinal model. An interim analysis for futility was incorporated. Simulations indicated the study had ≥85% power to detect a 14‐mm improvement and ≤1% risk for a placebo‐like drug to pass. The addition of the second success criterion substantially reduced the risk of an inadequate, weakly efficacious drug proceeding to future development. The study was terminated at the interim analysis due to inadequate analgesic efficacy. A Bayesian approach using probabilistic statements enables clear understanding of success criteria, leading to informed decisions for study conduct. Incorporating an interim analysis can effectively reduce sample size, save resources, and minimize exposure of patients to an inadequate treatment.     

Changing everyday activities of couples in late life: Converging and keeping up

The influence of mutual spousal interrelations in domains such as health and wellbeing has been demonstrated, but little is known about the domain of everyday activities of couples in late life. In the present explorative study, we considered all of the activities participating couples talked about to be their everyday activities. Its aim was to understand, over time, changes in everyday activities as experienced by late-life community-dwelling couples. In a two-year period, 41 individual and joint interviews were conducted with 8 couples, who were purposefully selected from the Longitudinal Aging Study Amsterdam. Analyses involved the construction of couple narratives and constant comparisons within and across couples. Changing everyday activities in late-life couples was interpreted to be a two-way process of (1) converging, and (2) keeping up, which occurred in three fluid phases. Converging was a slow inward movement with a shift towards diminished everyday activities performed in a smaller world. Keeping up was an outward movement in order to resist the converging process by using everyday activities as a means to keep fit, physically and mentally, and to connect with the wider social world. In the first phase, couples maintained their unique linked activity pattern. In the second phase, spouses resisted converging by keeping up. In the third phase, spouses co-performed everyday activities closely together. The findings support the need to develop couple-oriented interventions that aim to enhance the couples' functioning in the domain of everyday activities.     

Issues of Psychoanalytic Technique with Adoptees

Treatment issues relevant to the psychoanalytic treatment of the adoptee are presented; clinical formulation is encouraged within broad ego-diagnostic parameters. The adoptee's internal cathexis of the biological mother is identified as a core dynamic and the binary transference involving the adoptee's displaced relation to a dual set of parental representations is described. A metapsychological bias, predicated upon differential perceptions of the status of self and object representations is described and related to the adoptee's treatment. Various transference/countertransference dyads are discussed, as are corresponding technical considerations.