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Are self-management abilities beneficial for frail older people’s cognitive functioning?
BMC Geriatrics volume 22, Article number: 694 (2022)
Self-management abilities seem to be important for the cognitive functioning of older people, especially those who are frail. We investigated relationships between broad self-management abilities (initiative taking, investment behavior, resource variety, resource multifunctionality, self-efficacy, and positive frame of mind) and cognitive functioning among frail older people while controlling for background characteristics (sex, age, marital status, and educational level).
Survey data were collected from mid-2014 to mid-2015 from community-dwelling frail older people residing in North Brabant, the Netherlands. We measured cognitive functioning with the 12-item Mini-Mental State Examination (MMSE-12) and self-management abilities with the short version of the Self-Management Ability Scale (SMAS-S).
In total, 588 of 834 potential participants were willing to participate (70.5% response rate). The mean age was 82.33 ± 5.19 and the majority (68.5%) of respondents were female. About one-third (38.4%) of respondents had low educational levels and 61.7% lived alone. Mean MMSE-12 and SMAS-S scores were 9.68 ± 2.10 and 3.70 ± 0.88, respectively. Bivariate analyses showed that all six self-management abilities were related positively to cognitive functioning. Multivariate analyses with adjustment for background characteristics (sex, age, marital status, and educational level) showed that cognitive functioning was associated positively with initiative taking (β = 0.23, p = 0.030) and investment behavior (β = 0.24, p = 0.030) among community-dwelling frail older people.
This study clearly showed that a repertoire of broad self-management abilities is related to cognitive functioning among community-dwelling frail older people. Initiative taking and investment behavior seem to be especially important. These findings are of interest in a time of populational aging and an increasing number of older people dealing with cognitive problems. Preventive investments in (older) people’s self-management abilities are expected to be beneficial for their cognitive functioning in the long term.
Cognitive functioning has been identified as a key to successful health maintenance and aging [1,2,3,4,5]. Cognition refers to the ability to learn, solve problems, remember, and appropriately use stored information . As people age, their problems with cognitive function increase; after the age of 70 years, 16% of persons have mild cognitive impairment (MCI) and 14% experience dementia [1,2,3,4, 6]. Of those with dementia, about 67% have Alzheimer disease (AD) [4, 7, 8]. The development of cognitive impairment, dementia, and AD usually starts with a subtle decline in memory and difficulties with learning new things, followed by mild changes in executive cognitive function and difficulties with language and visuospatial processing . These changes are similar to the normal cognitive changes that occur with age, but are much more severe [9, 10]. While some mild changes in cognition, for example, are considered a normal part of the aging process, disease-related cognitive ageing is not. MCI and dementia are broad terms that indicate that there is a decline in cognition greater than would be expected for that person’s age, education or development. Such abnormal cognitive aging is especially seen among frail older people [11,12,13,14,15]. A systematic review of longitudinal studies performed by Kojima and colleagues  revealed significantly increased risks of dementia and mortality among frail older adults. Frailty can be seen as a syndrome in which more areas of functioning decline with aging; not only cognitive but also declines in social, physical and emotional functioning . It is therefore considered a multidimensional geriatric syndrome [17,18,19,20] with declines in multiple areas affecting each other. Frailty and cognitive impairment are among the 2 most common geriatric syndromes and their presence increases the risk of adverse outcomes such as the risks of falling, hospitalization, acute and chronic diseases, disability, and mortality [19, 21,22,23]. Research shows that frailty can be a risk factor for incident dementia. The opposite, however, is also true since older people with Alzheimer’s disease or dementia also present with more severe frailty .
Age-related cognitive change is variable and not inevitable; some people in their 70s and 80s retain excellent cognitive function and perform just as well or even better than their younger counterparts . Researchers have great interest in knowing what accounts for this variability and, especially, how to prevent cognitive decline. Self-management abilities seem to be important for older people’s cognitive functioning [26,27,28,29]. Steverink (e.g., [30, 31]) identified six broad self-management abilities that are important for older people’s well-being as they age: (1) the ability to take initiatives and be instrumental or self-motivating in realizing certain goals in life; (2) the ability to maintain a variety of resources; (3) the ability to invest in resources with a long-term perspective; (4) the ability to ensure resource multifunctionality (e.g., walking with a friend confers physical and social gains); (5) the ability to maintain a positive frame of mind despite the aging process; and (6) the ability to self-efficaciously manage resources. Although these abilities are important for people’s well-being [32,33,34,35], quality of life , health , and depressive symptoms , their relationship to cognitive functioning remains unknown. Gussekloo and colleagues  found that self-reliance and cognitive functioning seem to be related, with declines in the former leading to declines in the latter. Other studies have shown that better disease management skills are related to better cognitive functioning among older people with diabetes [26,27,28]. In addition, independence and engagement in physical activity have been found to be generally beneficial to cognitive functioning , and older people’s ability to generate emotional and instrumental support seems to delay the impairment of cognitive functioning . These studies, however, have demonstrated associations between particular self-management abilities and cognitive functioning; investigations of the relationships of a variety of self-management abilities to cognitive functioning are lacking. Inter-individual variability in cognitive functioning is likely attributable to a range of factors and mechanisms [40, 41]. Thus, this study was conducted to increase our understanding of relationships between the self-management abilities identified by Steverink [30, 31] and cognitive functioning among frail older people, with control for background characteristics (e.g., sex, age, marital status, and educational level). We focused on frail older people due to the particular importance of the prevention of cognitive function decline in this population [11,12,13,14,15], and because the use of frailty to select older people for interventions is better than selection based on age alone .
Design and participants
This survey-based study was part of the “Finding and Follow-up of Frail older persons” study, conducted to evaluate an integrated primary care approach to improve well-being among frail community-living older adults in North Brabant, the Netherlands . All community-dwelling people aged ≥75 years registered at the practices of 15 general practitioners (GPs) were selected for participation. They were then screened for frailty using the Tilburg Frailty Indicator (TFI)  during a home visit by the practice nurse, homecare nurse or geriatric nurse. The TFI assesses frailty in the physical, psychological, and social domains based on 15 items. Scores range from 0 to 15, and persons with scores ≥ 5 are identified as frail. However, older people with scores below 5 can still be identified as frail based on additional examination by professionals. Survey data were collected from mid-2014 to mid-2015. GPs assessed whether reasonable grounds to suspect incapacity to participate and/or give consent existed, and people were excluded in such cases. In total, 588 frail older people (of 834 potential participants) were willing to participate in the study (70.5% response rate). Those who were willing to participate were visited in their homes by interviewers (with healthcare backgrounds and training in conducting interviews); the study questionnaire was filled in face-to-face, which lasted 60–75 minutes. Given that we included frail older people we used validated shortened instruments whenever possible.
The medical research ethics committee of Erasmus Medical Centre, Rotterdam, the Netherlands, determined that the rules laid out in the Medical Research Involving Human Subjects Act did not apply to this study (protocol no. MEC-2014-444). The participants were informed in writing and during home visits about the study purpose and procedures and the assurance of confidentiality. They were also given contact information of the researchers in case they or their relatives had additional questions. Written informed consent to participate in the study was obtained from all participants.
Cognitive functioning was assessed with the 12-item Mini-Mental State Examination (MMSE-12) . This instrument is used to assess mental functions such as word recall, spatiotemporal orientation, and more complex tasks (doing math, folding a paper and putting it in one’s lap, drawing a figure). A “correct” (1) or “incorrect” (0) score is recorded for each of the 12 items (score range, 0–12), and higher total (summed) scores indicate better cognitive functioning.
Self-management abilities were assessed with the short (18-item) version of the Self-Management Ability Scale (SMAS-S) . This instrument is used to assess self-efficacy beliefs (e.g., are you able to have friendly contact with others?), a positive frame of mind (e.g., when you have a bad day, how often do you think that things will be better tomorrow?), initiative taking (e.g., how often do you make an effort to have friendly contact with other people?), investment behavior (e.g., do you devote some time and attention to those who are dear to you in order to maintain good contact?), resource multifunctionality (e.g., others benefit from the things I do for my pleasure), and resource variety (e.g., how many hobbies or activities do you engage in on a regular basis?). SMAS-S scores range from 1 to 6, with higher scores indicating better self-management abilities.
The questionnaire also solicited information about participants’ sex, age, marital status, and educational level. We dichotomized marital status as single/widowed/divorced (1) and married/living together (0), and educational level as elementary school or less (1) and more than elementary school (0).
Descriptive statistics were used to characterize the study population. Correlation analyses were used to assess correlations among background characteristics, self-management abilities, and cognitive functioning (using Pearson or Spearman correlations depending on the variables). Linear mixed-effects models with a random intercept (588 frail older persons nested in 15 GP practices) were employed to investigate relationships between self-management abilities and cognitive functioning, with adjustment for sociodemographic characteristics and listwise deletion of missing cases. Two-sided p values < 0.05 were considered to be significant. IBM SPSS (version 24 for Windows, IBM Corporation, Armonk, NY, USA) was used for all statistical analyses.
Respondents’ mean age was 82.33 ± 5.19 years, and the majority (68.5%) of respondents were female. About one-third (38.4%) of respondents had low educational levels, and 61.7% lived alone. Mean MMSE-12 and SMAS-S scores were 9.68 ± 2.10 and 3.70 ± 0.88, respectively (Table 1).
All six self-management abilities correlated positively with cognitive functioning (initiative taking, r = 0.293, p ≤ 0.001; investment behavior, r = 0.317, p ≤ 0.001; resource variety, r = 0.305, p ≤ 0.001; resource multifunctionality, r = 0.275, p ≤ 0.001; self-efficacy, r = 0.196, p ≤ 0.001; positive frame of mind, r = 0.100, p ≤ 0.05; Table 2). Older age (r = − 0.181, p ≤ 0.001) and low educational level (r = − 0.137, p ≤ 0.001) correlated negatively with cognitive functioning.
Adjusted multivariate analyses showed that cognitive functioning was associated positively with initiative taking (β = 0.23, p = 0.03) and investment behavior (β = 0.24, p = 0.03; Table 3). Total SMAS-S scores were associated positively with cognitive functioning (Additional file 1).
This study demonstrated the importance of a repertoire of broad self-management abilities for the cognitive functioning of community-dwelling frail older people, even after controlling for background characteristics. Bivariate associations were found between cognitive functioning and all six self-management abilities. Although correlations between some ability subscales were strong (0.6–0.7), factor loadings for the six dimensions are known to be high, indicating that the self-management abilities are separate, albeit related, concepts . Our multivariate analysis showed that investment behavior and the ability to take initiative are especially important for older people’s cognitive functioning. Schuurmans and colleagues  suggested that these abilities are key for older people’s achievement of well-being, as abilities to take action are especially relevant for (pro)active resource management. For example, self-efficacy alone is not sufficient to achieve well-being  or prevent cognitive decline (this study); specific actions need to be taken for people to achieve desired results based on their intentions.
To combat further cognitive problems among older people at the early stages of cognitive declines, investment in self-management abilities at an early stage may be worthwhile. Randomized controlled studies have shown that the six self-management abilities can be taught effectively to community-dwelling older people with interventions, even those who are frail or dealing with loneliness [47,48,49,50]. These studies clearly showed that because (frail) older people lack reserves in multiple life domains, they especially benefit from self-management interventions that provide them with a general cognitive and behavioral repertoire for dealing with different kinds of age-related problems rather than from interventions focusing on one specific problem [e.g., 47]. The improvement of these abilities may prevent cognitive decline among older people (to some extent). Special attention to action-related self-management abilities (initiative taking and investment behavior) may be especially worthwhile, but additional research is needed to confirm this hypothesis.
Several limitations of this study should be taken into account. First, the cross-sectional nature of the data prevented us from drawing causal conclusions. Relationships between self-management abilities and cognitive functioning are expected to be dynamic; poorer cognitive functioning, for example, may limit older people’s ability to take initiative. Longitudinal studies are needed to disentangle these relationships. Second, we assessed cognitive functioning using a questionnaire administered during face-to-face interviews. The MMSE is one of the most widely used instruments to detect cognitive impairment in older people. Although research shows the MMSE is a good and reliable instrument to detect severe cognitive impairment [51,52,53,54,55] it may be more difficult to detect MCI and those in the early stages of dementia . However, the MMSE-12 is validated for this purpose, which is why we used this instrument. We treated missing item responses as “incorrect” (0), given that they might indicate that people had problems answering the questions. We also performed analyses with the exclusion of 115 respondents with missing items (ranging from 2.2% to 11.9% on each item), which yielded similar results. Third, we included only frail older people, among whom poor cognitive functioning is known to be more prevalent than in the general older population [57, 58]. Additional research is needed to assess relationships between self-management abilities and cognitive functioning in the general older population. Finally, we did not include the role of depressive and anxious symptoms on self-management abilities, which are expected to be especially related to having a positive frame of mind. Given that the TFI  was used to detect frailty in older people already which includes two items about depressive symptoms (Have you felt down during the last month?) and anxious symptoms (Have you felt nervous or anxious during the last month?), we chose not to include such instruments. These could be investigated in future research.
This study clearly showed that the possession of a repertoire of broad self-management abilities is related to cognitive functioning among community-dwelling frail older people. Initiative taking and investment behavior seem to be especially important. These findings are of interest in a time of population aging, with an increase in the number of older people dealing with cognitive problems. Preventive investments in (older) people’s self-management abilities are likely to be beneficial for their cognitive functioning in the longer term.
Availability of data and materials
The datasets generated and analyzed during the current study are not available publicly, but are available from the corresponding author on reasonable request.
12-item Mini-Mental State Examination
Self-Management Ability Scale, short version
Petersen RC. Clinical practice: mild cognitive impairment. N Engl J Med. 2011;364:2227–34.
Morley JE. Mild cognitive impairment: a treatable condition. J Am Med Dir Assoc. 2014;15:1–5.
Ferri CP, Prince M, Brayne C, et al. Global prevalence of dementia: a Delphi consensus study. Lancet. 2005;366:2112–7.
Hugo J, Ganguli M. Dementia and cognitive impairment: epidemiology, diagnosis, and treatment. Clin Geriatr Med. 2014;30:421–42.
Morley JE, et al. Brain health: the importance of recognizing cognitive impairment: an IAGG consensus conference. J Am Med Dir Assoc. 2016;16:731–9.
Gauthier S, Reisberg B, Zaudig M, et al. Mild cognitive impairment. Lancet. 2006;367:1262–70.
Zhang Y, Xu Y, Nie H, et al. Prevalence of dementia and major dementia subtypes in the Chinese populations: a meta-analysis of dementia prevalence surveys, 1980–2010. J Clin Neurosci. 2012;19:1333–7.
de Pedro-Cuesta J, Virues-Ortega J, Vega S, et al. Prevalence of dementia and major dementia subtypes in Spanish populations: a re-analysis of dementia prevalence surveys, 1990–2008. BMC Neurol. 2009;9:55.
Fjell AM, McEvoy L, Holland D, et al. Alzheimer's disease neuroimaging initiative. What is normal in normal aging? Effects of aging, amyloid and Alzheimer's disease on the cerebral cortex and the hippocampus. Prog Neurobiol. 2014;117:20–40.
Morris JC, Price JL. Pathologic correlates of nondemented aging, mild cognitive impairment, and early-stage Alzheimer's disease. J Mol Neurosci. 2001;17101–18.
Avila-Funes JA, Carcaillon L, Helmer C, et al. Is frailty a prodromal stage of vascular dementia? Results from the Three-City study. J Am Geriatr Soc. 2012;60:1708–12.
Buchman AS, Boyle PA, Wilson RS, et al. Frailty is associated with incident Alzheimer’s disease and cognitive decline in the elderly. Psychosom Med. 2007;69:483–9.
Gray SL, Anderson ML, Hubbard RA, et al. Frailty and incident dementia. J Gerontol A Biol Sci Med Sci. 2013;68:1083–90.
Kojima G, Taniguchi Y, Ilife S, Walters K. Frailty as a predictor of Alzheimer disease, vascular dementia, and all dementia among community-dwelling older people: a systematic review and meta-analysis. J Am Med Dir Assoc. 2016;17:881–8.
Solfrizzi V, Scafato E, Frisardi V, et al. Frailty syndrome and the risk of vascular dementia: The Italian longitudinal study on aging. Alzheimers Dement. 2013;9:113–22.
Verbrugge LM, et al. In: Carey R, Robin J-M, Michel J-P, editors. Flies without wings. Longevity and frailty. Heidelberg: Springer; 2005. p. 67–81.
Bauer JM, Sieber CC. Sarcopenia and frailty: a clinician’s controversial point of view. Exp Gerontol. 2008;43:674–8. https://doi.org/10.1016/j.exger.2008.03.007.
Bergman H, Beland F, Lebel P, Contandriopoulos AP, Tousignant P, Brunelle Y, et al. Caring for Canada’s frail elderly population: fragmentation or integration? CMAJ. 1997;157:1116–20.
Markle-Reid M, Browne G. Conceptualizations of frailty in relation to older adults. J Adv Nurs. 2003;44(1):58–68. https://doi.org/10.1046/j.1365-2648.2003.02767.x.
Gobbens RJJ, van Assen MALM, Luijkx KG, Wijnen-Sponselee MT. Schols JMGA: The Tilburg Frailty Indicator: psychometric properties. J Am Med Dir Assoc. 2010;11(5):344–55. https://doi.org/10.1016/j.jamda.2009.11.003.Glisky EL. Changes in cognitive function in human aging. In: Riddle DR, editor. Brain aging: models, methods, and mechanisms. Boca Raton, FL: CRC Press/Taylor & Francis; 2007.
Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Cardiovascular health study collaborative research group: Frailty in older adults: evidence for a phenotype. J Gerontol A Bio Sci Med Sci. 2001;56:146–56. https://doi.org/10.1093/gerona/56.3.M146.
Levers MJ, Estabrooks CA, Ross Kerr JC. Factors contributing to frailty: literature review. J Adv Nurs. 2006;56(3):282–91. https://doi.org/10.1111/j.1365-2648.2006.04021.x.
Pel Littel RE, Schuurmans MJ, Emmelot Vonk MH, Verhaar HJ. Frailty: defining and measuring of a concept. J Nutr Health Aging. 2009;13(4):390–4. https://doi.org/10.1007/s12603-009-0051-8.
Fabrício DM, Chagas MHN, Diniz BS. Frailty and cognitive decline. Transl Res. 2020;221:58–64. https://doi.org/10.1016/j.trsl.2020.01.002 Epub 2020 Jan 23. PMID: 32045578.
Gussekloo J, de Craen AJ, Van Exel E, et al. Oorzaken en gevolgen van cognitieve achteruitgang op hoge leeftijd; de'Leiden 85-plus Studie'. Ned Tijdschr Geneeskd. 2004;148:979–83.
Asimakopoulou K, Hampson SE. Cognitive functioning and self-management in older people with diabetes. Diabetes Spectr. 2002;15:116–21.
Sinclair AJ, Girling AJ, Bayer AJ. Cognitive dysfunction in older subjects with diabetes mellitus: impact on diabetes self-management and use of care services. Diabetes Res Clin Pract. 2000;2000(50):203–12.
Feil DG, Zhu CW, Sultzer DL. The relationship between cognitive impairment and diabetes self-management in a population-based community sample of older adults with type 2 diabetes. J Behav Med. 2012;35:190–9.
Ellwardt L, Aartsen M, Deeg D, Steverink N. Does loneliness mediate the relation between social support and cognitive functioning in later life? Soc Sci Med. 2013;98:116–24.
Steverink N. Successful development and aging: theory and intervention. In: Pachana NA, Laidlaw K, editors. The Oxford handbook of geropsychology. Oxford: Oxford University Press; 2014.
Steverink, N. Self-management ability scale: SMAS-30/versie 2. achtergrond, handleiding en scoring [Self-management ability scale: SMAS-30/version 2. background, manual and scoring]. 2009. www.nardisteverink.nl. .
Steverink N, Lindenberg S. Do good self-managers have less physical and social resource deficits and more well-being in later life? Eur J Ageing. 2008;5:181–90.
Cramm JM, Nieboer AP. Disease management: the need for a focus on broader self-management abilities and quality of life. Popul Health Manag. 2015;18:246–55.
Cramm JM, Nieboer AP. Chronically ill patients' self-management abilities to maintain overall well-being: what is needed to take the next step in the primary care setting? BMC Fam Pract. 2015;16:123.
Cramm JM, Hartgerink JM, Bakker TJ, et al. Understanding older patients’ self-management abilities: functional loss, self-management, and well-being. Qual Life Res. 2013;22:85–92.
Cramm JM, Nieboer AP. Self-management abilities and quality of life among frail community-dwelling peoples; the role of community nurses in the Netherlands. Health Soc Care Community. 2017;2:394–401.
Cramm JM, Hartgerink JM, de Vreede PL, Bakker TJ, Steyerberg EW, Mackenbach JP, et al. The relationship between older adults' self-management abilities, well-being and depression. Eur J Ageing. 2012;9:353–60.
Cramm JM, Nieboer AP. Self-management abilities, physical health and depressive symptoms among patients with cardiovascular diseases, chronic obstructive pulmonary disease, and diabetes. Patient Educ Couns. 2012;87:411–5.
Colcombe S, Kramer AF. Fitness effects on the cognitive function of older adults: a meta-analytic study. Psychol Sci. 2003;14:125.
Grady CL, et al. The effects of encoding task on age-related differences in the functional neuroanatomy of face memory. Psychol Aging. 2002;17:7.
Cabeza R, et al. Aging gracefully: compensatory brain activity in high-performing older adults. NeuroImage. 2002;17:1394.
Schuurmans H, Steverink N, Lindenberg S, et al. Old or frail: what tells us more? J Gerontol A Biol Sci Med Sci. 2004;59:M962–5. https://doi.org/10.1093/gerona/59.9.M962.
Vestjens L, Cramm JM, Birnie E, Nieboer AP. Evaluating an integrated primary care approach to improve well-being among frail community-living older people: a theory-guided study protocol. BMC Geriatr. 2018;18:173.
Kempen GIJM, Brilman EI, Ormel J. The Mini mental status examination: normative data and a comparison of a 12-item and 20-item version in a sample survey of community-based elderly. Tijdschr Gerontol Geriatr. 1995;26:163–72.
Cramm JM, Strating MMH, de Vreede PL, Steverink N, Nieboer AP. Validation of the self-management ability scale (SMAS) and development and validation of a shorter scale (SMAS-S) among older patients shortly after hospitalisation. Health Qual Life Outcomes. 2012;10:9.
Schuurmans H, Steverink N, Frieswijk N, Buunk BP, Slaets JP, Lindenberg S. How to measure self-management abilities in older people by self-report. The development of the SMAS-30. Qual Life Res. 2005;14(10):2215–28.
Frieswijk N, Steverink N, Buunk BP, Slaets JPJ. The effectiveness of a bibliotherapy in increasing the self-management ability of slightly to moderately frail older people. Patient Educ Couns. 2006;61:219–27.
Goedendorp MM, Steverink N. Interventions based on self-management of well-being theory: pooling data to demonstrate mediation and ceiling effects, and to compare formats. Aging Ment Health. 2017;21:947–53.
Kremers IP, Steverink N, Albersnagel FA, JPJ S. Improved self-management ability and well-being in older women after a short group intervention. Aging Ment Health. 2006;10:476–84.
Schuurmans H. Promoting well-being in frail elderly people: theory and intervention [dissertation]. Groningen: Groningen University; 2004.
Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–98.
Lezak MD, Howieson DB, Loring DW. Neuropsychological assessment. 4th ed. New York, NY: Oxford University Press; 2004.
O’Connor DW, Pollitt PA, Hyde JB, Fellows JL, Miller ND, Brook CP, et al. The reliability and validity of the Mini-mental state in a British community survey. J Psychiatry Res. 1989;23:87–96.
Kang Y, Na DL, Hahn SH. A validity study on the Korean version of Mini-mental state examination in dementia patients. J Korean Neurol Assoc. 1997;15:300–7.
Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive review. J Am Geriatr Soc. 1992:922–35.
Nys GMS, van Zandvoort MJE, de Kort PLM, Jansen BPW, Kappelle LJ, de Haan EHF. Restrictions of the Mini-mental state examination in acute stroke. Arch Clin Neuropsychol. 2005;20:623–9.
Aprahamian I, Suemoto CK, Aliberti MJR, et al. Frailty and cognitive status evaluation can better predict mortality in older adults? Arch Gerontol Geriatr. 2018;77:51–6. https://doi.org/10.1016/j.archger.2018.04.005.
Jacobs JM, Cohen A, Ein-Mor E, Maaravi Y, Stessman J. Frailty, cognitive impairment and mortality among the oldest old. J Nutr Health Aging. 2011;15:678–82.
The authors acknowledge all of the GP practices and participants who participated in this study.
The implementation of the Finding and Follow-up of Frail older persons approach and the study evaluating it were supported financially by the healthcare organizations TWB Thuiszorg met Aandacht, Stichting Groenhuysen, Stichting tanteLouise-Vivensis, and Zorggroep West-Brabant. They were also financed in part by the health insurers CZ and VGZ. The funding bodies were not involved in the design of the study; collection, analysis, or interpretation of data; or writing of the manuscript.
Ethics approval and consent to participate
The medical ethics committee of Erasmus Medical Centre, Rotterdam, the Netherlands determined that the rules laid down in the Medical Research Involving Human Subjects Act did not apply to this study (protocol no. MEC-2014-444), and waived the need for further examination for ethical approval beyond the initial protocol review. Written informed consent to participate in the study was obtained from all participants. All methods were performed in accordance with the relevant guidelines and regulations.
Consent for publication
The data we obtained from the participants are unidentifiable. Consent for publication was thus not required.
Jane Murray Cramm is an associate editor of BMC Geriatrics. The authors declare that they have no other competing interest.
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Relationships of background characteristics and self-management abilities to cognitive functioning among frail older people (n = 571; multivariate linear mixed-effects models)
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Cramm, J.M., Nieboer, A.P. Are self-management abilities beneficial for frail older people’s cognitive functioning?. BMC Geriatr 22, 694 (2022). https://doi.org/10.1186/s12877-022-03353-4
- Cognitive functioning
- Older people