Effectiveness of a Geriatric Care Model for frail older adults in primary care: Results from a stepped wedge cluster randomized trial.

BACKGROUND: Primary care-based comprehensive care programs have the potential to improve outcomes in frail older adults. We evaluated the impact of the Geriatric Care Model (GCM) on the quality of life of community-dwelling frail older adults. METHODS: A 24-month stepped wedge cluster randomized controlled trial was conducted between May 2010 and March 2013 in 35 primary care practices in the Netherlands, and included 1147 frail older adults. The intervention consisted of a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Reassessment occurred every six months. Nurses worked together with primary care physicians and were supervised and trained by geriatric expert teams. Complex patients were reviewed in multidisciplinary consultations. The primary outcome was quality of life (SF-12). Secondary outcomes were health-related quality of life, functional limitations, self-rated health, psychological wellbeing, social functioning and hospitalizations. RESULTS: Intention-to-treat analyses based on multilevel modeling showed no significant differences between the intervention group and usual care regarding SF-12 and most secondary outcomes. Only for IADL limitations we found a small intervention effect in patients who received the intervention for 18months (B=-0.25, 95%CI=-0.43 to -0.06, p=0.007), but this effect was not statistically significant after correction for multiple comparisons. CONCLUSION: The GCM did not show beneficial effects on quality of life in frail older adults in primary care, compared to usual care. This study strengthens the idea that comprehensive care programs add very little to usual primary care for this population. TRIAL REGISTRATION: The Netherlands National Trial Register NTR2160.

Do psychosocial resources modify the effects of frailty on functional decline and mortality?

OBJECTIVE: Little is known about factors that may prevent or delay adverse health outcomes in frail older adults. Previous studies have demonstrated beneficial effects of psychosocial resources on health outcomes in older adults. The aim of this study was to investigate whether psychosocial resources modify the effects of frailty on functional decline and mortality. METHODS: The study sample consisted of 1665 men and women aged 58 and over from two waves of the Longitudinal Aging Study Amsterdam (LASA), a population based study. Frailty and psychosocial resources were assessed at T1 (2005/2006). Frailty was assessed using the criteria of Fried's phenotype. Psychosocial resources included sense of mastery, self-efficacy, instrumental support and emotional support. Functional decline and mortality were assessed at T2 (2008/2009). RESULTS: Results of logistic regression analyses demonstrated that frail older adults had higher odds of both functional decline (OR=2.63, 95% CI=1.61-4.27) and 3-year mortality (OR=3.17, 95% CI=1.95-5.15). After adjustment for covariates, higher levels of mastery and self-efficacy were associated with decreased odds of functional decline, but not mortality. No statistically significant interaction effects between frailty and psychosocial resources were found for either functional decline or mortality. CONCLUSION: This study found no evidence that psychosocial resources buffer against functional decline and mortality in frail older adults.

Explaining the association between educational level and frailty in older adults: results from a 13-year longitudinal study in the Netherlands.

PURPOSE: The aim of this study was to examine the longitudinal association between educational level and frailty prevalence in older adults and to investigate the role of material, biomedical, behavioral, social, and mental factors in explaining this association. METHODS: Data over a period of 13 years were used from the Longitudinal Aging Study Amsterdam. The study sample consisted of older adults aged 65 years and above at baseline (n = 1205). Frailty was assessed using Fried's frailty criteria. A relative index of inequality was calculated for the level of education. Longitudinal logistic regression analyses based on multilevel modeling were performed. RESULTS: Older adults with a low educational level had higher odds of being frail compared with those with a high educational level (relative index of inequality odds ratio, 2.94; 95% confidence interval, 1.84-4.71). These differences persisted during 13 years of follow-up. Adjustment for all explanatory factors reduced the effect of educational level on frailty by 76%. Income, self-efficacy, cognitive impairment, obesity, and number of chronic diseases had the largest individual contribution in reducing the effect. Social factors had no substantial contribution. CONCLUSIONS: Our findings highlight the need for a multidimensional approach in developing interventions aimed at reducing frailty, especially in lower educated groups.

Variability between nursing homes in prevalence of antipsychotic use in patients with dementia.

BACKGROUND: Antipsychotic drugs (APD) are widely prescribed for people with dementia residing in long term care facilities (LTCFs). Concern has been expressed that such prescribing is largely inappropriate. The objective of this study is to examine if differences in facility-level prevalence of APD use in a sample of LTCFs for patients with dementia can be explained by patient and facility-related characteristics. METHODS: A point prevalence study was conducted using data from the VU University Resident Assessment Instrument (VURAI) database from nursing homes and residential care facilities in the Netherlands. Patients were selected who had a diagnosis of dementia. LTCF and patient characteristics were extracted from the VURAI; facility-level resident satisfaction surveys were provided by the National Institute for Public Health. RESULTS: In total, 20 LTCFs providing care for 1,090 patients with dementia were investigated. Overall, 31% of patients used an APD. In facilities with a high prevalence of APD use behavioral symptoms were present in 62% of their patients. In facilities with medium APD use behavioral problems remained frequent (57%), and in facilities with low prevalence of APD use 54% of the patients had behavioral symptoms. Facilities with a high prevalence of APD use were often large, situated in urban communities, and scored below average on staffing, personal care, and recreational activities. CONCLUSIONS: There was considerable variation between the participating LTCFs in the prevalence of APD use. Variability was related to LTCF characteristics and patient satisfaction. This indicates potential inappropriate prescribing because of differences in institutional prescribing culture.

Self-perceived met and unmet care needs of frail older adults in primary care.

In order to provide adequate care for frail older adults in primary care it is essential to have insight into their care needs. Our aim was to describe the met and unmet care needs as perceived by frail older adults using a multi-dimensional needs assessment, and to explore their associations with socio-demographic and health-related characteristics. Cross-sectional baseline data were used from the Frail older Adults: Care in Transition (ACT) study in the Netherlands, consisting of 1137 community dwelling frail older adults aged 65 and above. Patients were recruited through 35 primary care practices. Self-perceived care needs were assessed using the Camberwell Assessment of Need for the Elderly (CANE). Socio-demographic characteristics included age, sex, partner status and educational level. Health-related characteristics included functional capacity, hospital admissions, chronic diseases and the degree of frailty. Frail older adults reported on average 4.2 care needs out of 13 CANE topics, of which 0.5 were unmet. The physical and environmental domain constituted the highest number of needs, but these were mostly met. Unmet needs were mainly found in the psychosocial domain. Regression analyses revealed that Activities of Daily Living (ADL) limitations and a higher frailty score were the most important determinants of both met and unmet care needs. A younger age and a higher educational level were associated with the presence of unmet care needs. In conclusion, most frail older adults in primary care report to receive sufficient help for their physical needs. More attention should be paid to their psychosocial needs.

The calculation of quality indicators for long term care facilities in 8 countries (SHELTER project).

BACKGROUND: Performance indicators in the long term care sector are important to evaluate the efficiency and quality of care delivery. We are, however, still far from being able to refer to a common set of indicators at the European level.We therefore demonstrate the calculation of Long Term Care Facility Quality Indicators (LTCFQIs) from data of the European Services and Health for Elderly in Long TERm Care (SHELTER) project. We explain how risk factors are taken into account and show how LTC facilities at facility and country level can be compared on quality of care using thresholds and a Quality Indicator sum measure. METHODS: The indicators of Long Term Care Facility quality of care are calculated based on methods that have been developed in the US. The values of these Quality Indicators (QIs) are risk adjusted on the basis of covariates resulting from logistic regression analysis on each of the QIs. To enhance the comparison of QIs between facilities and countries we have used the method of percentile thresholds and developed a QI sum measure based on percentile outcomes. RESULTS: In SHELTER data have been collected with the interRAI Long Term Care Facility instrument (interRAI-LTCF). The data came from LTC facilities in 7 European countries and Israel. The unadjusted values of the LTCF Quality Indicators differ considerably between facilities in the 8 countries. After risk adjustment the differences are less, but still considerable. Our QI sum measure facilitates the overall comparison of quality of care between facilities and countries. CONCLUSIONS: With quality indicators based on assessments with the interRAI LTCF instrument quality of care between LTC facilities in and across nations can be adequately compared.

Apathy and weight loss in nursing home residents: longitudinal study.

OBJECTIVES: Determine which behavioral syndromes of dementia are independently related to weight loss. DESIGN: Longitudinal study using four subsequent quarterly Minimum Data Set (MDS) 2.0 assessments. Characteristics obtained in one period were related to weight loss observed in the next period. SETTING: Eight nursing homes in the Netherlands. PARTICIPANTS: The initial population was 2031 nursing home residents with four quarterly MDS assessments within a period of 15 months. We selected 1850 subjects who were at least 65 years old at the time of the first assessment and who were not comatose. MEASUREMENTS: Information about the presence of four behavioral syndromes (depression, apathy, agitation, and rejection of care), demographic data, cognition status, body mass index (BMI), and time that residents were involved in activities were obtained from MDS 2.0. RESULTS: Bivariate correlation showed that weight loss at follow-up assessments was related to all baseline behavioral syndromes, degree of cognitive impairment, body mass index, and time that residents were involved in activities. Multivariable binary logistic regression with these factors showed that the only behavioral syndrome that was independently related to subsequent weight loss was apathy. In multivariable analysis, the degree of cognitive impairment and BMI were also independently related to weight loss. CONCLUSION: These results suggest that of all behavioral factors we have assessed, apathy had the strongest association with weight loss in nursing home residents even when adjusted for the degree of cognitive impairment.

Involvement in activities and wandering in nursing home residents with cognitive impairment.

OBJECTIVES: Analysis of a relationship between wandering and involvement in meaningful activities in nursing home residents with cognitive impairment. DESIGN: Cross-sectional analysis of the minimum data set information. SETTING: The analyses were conducted on 8 nursing homes in the Netherlands. PARTICIPANTS: The participants were residents aged 65 years and above with an evidence of cognitive impairment. MEASUREMENTS: Items in the minimum data set related to wandering behavior, involvement in activities, presence of psychotic symptoms, and treatment with antipsychotics. Ambulatory residents who exhibited wandering were divided into: those whose behavior was easily altered [modifiable wandering (MW)] and those whose wandering behavior was not easily altered by the staff [nonmodifiable wandering (NMW)]. The duration of time for which they had opportunity to be involved in meaningful activities was estimated from involvement in activities of nonambulatory residents. RESULTS: The prevalence of wandering increased with severity of cognitive impairment. MW was present in 3.5% of total residents (8.5% of ambulatory), whereas NMW was present in 11.2% of the total ambulatory and nonambulatory residents (26.6% of ambulatory). The risk of NMW was increased with resistiveness to care and decreased with antipsychotic use. Individuals with NMW were less involved in activities. NMW was more prevalent in facilities in which residents were involved in activities for a shorter duration. CONCLUSIONS: Involvement of residents in meaningful activities should be tested for reducing the incidence of problematic wandering and for decrease in usage of antipsychotic medications.

The diagnosis of depression and use of antidepressants in nursing home residents with and without dementia.

OBJECTIVE: To compare the prevalence of diagnosed depressive disorders, depressive symptoms and use of antidepressant medication between nursing home residents with and without dementia. METHODS: This cross-sectional study used Minimal Data Set of the Resident Assessment Instrument 2.1 data collected in seven nursing homes located in an urbanized region in the Netherlands. Trained nurse assistants recorded all medical diagnoses made by a medical specialist, including dementia and depressive disorder, and medication use. Depressive symptoms were measured with the Depression Rating Scale. Multivariate logistic regression analysis was used to compare data between residents with and without dementia. RESULTS: Included in the study were 1885 nursing home residents (aged 65 years or older), of which 837 had dementia. There was no significant difference in the prevalence of diagnosed depressive disorder between residents with (9.6%) and without dementia (9.8%). Residents with dementia (46.4%) had more depressive symptoms than residents without dementia (22.6%). Among those with depressive symptoms, residents with dementia had the same likelihood of being diagnosed with a depressive disorder as residents without dementia. Among residents with a diagnosed depressive disorder, antidepressant use did not differ significantly between residents with dementia (58.8%) and without dementia (57.3%). The same holds true for residents with depressive symptoms, where antidepressant use was 25.3% in residents with dementia and 24.6% in residents without dementia. CONCLUSIONS: Regarding the prevalence rates of diagnosed depressive disorder and antidepressant use found in this study, our findings demonstrate that there is room for improvement not only for the detection of depression but also with regard to its treatment.

The identification of frail older adults in primary care: comparing the accuracy of five simple instruments.

BACKGROUND: many instruments are available to identify frail older adults who may benefit from geriatric interventions. Most of those instruments are time-consuming and difficult to use in primary care. OBJECTIVE: to select a valid instrument to identify frail older adults in primary care, five simple instruments were compared. METHODS: instruments included clinical judgement of the general practitioner, prescription of multiple medications, the Groningen frailty indicator (GFI), PRISMA-7 and the self-rated health of the older adult. Fried's frailty criteria and a clinical judgement by a multidisciplinary expert panel were used as reference standards. Data were used from the cross-sectional Dutch Identification of Frail Elderly Study consisting of 102 people aged 65 and over from a primary care practice in Amsterdam. In this study, frail older adults were oversampled. We estimated the accuracy of each instrument by calculating the area under the ROC curve. The agreement between the instruments and the reference standards was determined by kappa. RESULTS: frailty prevalence rates in this sample ranged from 11.6 to 36.4%. The accuracy of the instruments ranged from poor (AUC = 0.64) to good (AUC = 0.85). CONCLUSION: PRISMA-7 was the best of the five instruments with good accuracy. Further research is needed to establish the predictive validity and clinical utility of the simple instruments used in this study.

Is it time for a change? A cost-effectiveness analysis comparing a multidisciplinary integrated care model for residential homes to usual care.

OBJECTIVE: The objective of this study was to evaluate the cost-effectiveness of a Multidisciplinary Integrated Care (MIC) model compared to Usual Care (UC) in Dutch residential homes. METHODS: The economic evaluation was conducted from a societal perspective alongside a 6 month, clustered, randomized controlled trial involving 10 Dutch residential homes. Outcome measures included a quality of care weighted sum score, functional health (COOP WONCA) and Quality Adjusted Life-Years (QALY). Missing cost and effect data were imputed using multiple imputation. Bootstrapping was used to analyze differences in costs and cost-effectiveness. RESULTS: The quality of care sum score in MIC was significantly higher than in UC. The other primary outcomes showed no significant differences between the MIC and UC. The costs of providing MIC were approximately €225 per patient. Total costs were €2,061 in the MIC group and €1,656 for the UC group (mean difference €405, 95% -13; 826). The probability that the MIC was cost-effective in comparison with UC was 0.95 or more for ceiling ratios larger than €129 regarding patient related quality of care. Cost-effectiveness planes showed that the MIC model was not cost-effective compared to UC for the other outcomes. INTERPRETATION: Clinical effect differences between the groups were small but quality of care was significantly improved in the MIC group. Short term costs for MIC were higher. Future studies should focus on longer term economic and clinical effects. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN11076857.

Relationship between symptoms of depression and agitation in nursing home residents with dementia.

OBJECTIVE: The aim of this study is to analyze modifiable factors related to agitation of nursing home residents with dementia. METHODS: Relationship of agitation with three modifiable factors (depression, psychosis, and pain) was explored using longitudinal Minimum Data Set (MDS) information from 2032 residents of Dutch nursing homes. Presence of agitation and depression was ascertained using validated scales based on MDS information. Presence of psychosis and pain was ascertained from the individual MDS items. RESULTS: There was a significant correlation between MDS depression and agitation scores. Depression scores increased in residents whose agitation worsened and decreased in residents whose agitation improved. Psychosis scores (combination of delusions and hallucinations) also correlated with MDS depression scores, and psychosis scores increased in residents whose agitation worsened. Pain scores correlated with agitation scores, but the pain scores did not change with changes in agitation. Depression symptoms were present in 51% of residents, while psychotic symptoms were present only in 15% of residents, and two-thirds of these residents were also depressed. CONCLUSION: These results indicate that depression may be the most common factor associated with agitation in nursing home residents with dementia.

The prevalence, incidence and risk factors for delirium in Dutch nursing homes and residential care homes.

OBJECTIVE: To estimate and compare the prevalence and incidence of delirium and its risk factors in residents of Dutch nursing homes and residential care homes. METHODS: Data were extracted from the Long-Term Care Facility (inter RAI-LTCF) version of the Resident Assessment Instrument, which was filled in a routine care cohort for a total of 3627 residents. 828 residents of six nursing homes and 1365 residents of 23 residential homes were included in the analyses. Delirium was defined as a positive score on the adjusted Nursing Home-CAM. RESULTS: The prevalence of delirium was 8.9% in the nursing homes and 8.2% in the residential homes. The incidence was highest in the nursing homes with 20.7 versus 14.6 per 100 person-years. Multivariate tests of risk factors for developing delirium included chair restraints (OR 2.3; 95% CI 1.27-4.28), dementia (odds ratio (OR) 3.3; 95% confidence interval (CI) 2.03-5.24) and Parkinson's disease (OR 2.3; 95% CI 0.96-5.63) for residents in nursing homes, and dementia (OR 1.8; 95% CI 1.31-2.55) and fall incidents (OR 1.7; 95% CI 1.20-2.48) for residents in residential care homes. CONCLUSION: The prevalence and incidence of delirium was high in both nursing homes and residential care homes. More focus on modifiable risk factors such as the use of restraints in nursing homes and fall incidents in residential care homes may help to prevent delirium.

Effects of multidisciplinary integrated care on quality of care in residential care facilities for elderly people: a cluster randomized trial.

BACKGROUND: Sophisticated approaches are needed to improve the quality of care for elderly people living in residential care facilities. We determined the effects of multidisciplinary integrated care on the quality of care and quality of life for elderly people in residential care facilities. METHODS: We performed a cluster randomized controlled trial involving 10 residential care facilities in the Netherlands that included 340 participating residents with physical or cognitive disabilities. Five of the facilities applied multidisciplinary integrated care, and five provided usual care. The intervention, inspired by the disease management model, consisted of a geriatric assessment of functional health every three months. The assessment included use of the Long-term Care Facility version of the Resident Assessment Instrument by trained nurse-assistants to guide the design of an individualized care plan; discussion of outcomes and care priorities with the family physician, the resident and his or her family; and monthly multidisciplinary meetings with the nurse-assistant, family physician, psychologist and geriatrician to discuss residents with complex needs. The primary outcome was the sum score of 32 risk-adjusted quality-of-care indicators. RESULTS: Compared with the facilities that provided usual care, the intervention facilities had a significantly higher sum score of the 32 quality-of-care indicators (mean difference - 6.7, p = 0.009; a medium effect size of 0.72). They also had significantly higher scores for 11 of the 32 indicators of good care in the areas of communication, delirium, behaviour, continence, pain and use of antipsychotic agents. INTERPRETATION: Multidisciplinary integrated care resulted in improved quality of care for elderly people in residential care facilities compared with usual care. TRIAL REGISTRATION: www.controlled-trials.com trial register no. ISRCTN11076857.

Communication, advice exchange and job satisfaction of nursing staff: a social network analyses of 35 long-term care units.

BACKGROUND: The behaviour of individuals is affected by the social networks in which they are embedded. Networks are also important for the diffusion of information and the influence of employees in organisations. Yet, at the moment little is known about the social networks of nursing staff in healthcare settings. This is the first study that investigates informal communication and advice networks of nursing staff in long-term care. We examine the structure of the networks, how they are related to the size of units and characteristics of nursing staff, and their relationship with job satisfaction. METHODS: We collected social network data of 380 nursing staff of 35 units in group projects and psychogeriatric units in nursing homes and residential homes in the Netherlands. Communication and advice networks were analyzed in a social network application (UCINET), focusing on the number of contacts (density) between nursing staff on the units. We then studied the correlation between the density of networks, size of the units and characteristics of nursing staff. We used multilevel analyses to investigate the relationship between social networks and job satisfaction of nursing staff, taking characteristics of units and nursing staff into account. RESULTS: Both communication and advice networks were negatively related to the number of residents and the number of nursing staff of the units. Communication and advice networks were more dense when more staff worked part-time. Furthermore, density of communication networks was positively related to the age of nursing staff of the units. Multilevel analyses showed that job satisfaction differed significantly between individual staff members and units and was influenced by the number of nursing staff of the units. However, this relationship disappeared when density of communication networks was added to the model. CONCLUSIONS: Overall, communication and advice networks of nursing staff in long-term care are relatively dense. This fits with the high level of cooperation that is needed to provide good care to residents. Social networks are more dense in small units and are also shaped by characteristics of staff members. The results furthermore show that communication networks are important for staff's job satisfaction.

Social engagement and depressive symptoms of elderly residents with dementia: a cross-sectional study of 37 long-term care units.

BACKGROUND: Social engagement and depression are important outcomes for residents with dementia in long-term care. However, it is still largely unclear which differences in social engagement and depression exist in residents of various long-term care settings and how these differences may be explained. This study investigated the relationship between social engagement and depressive symptoms in long-term care dementia units, and studied whether differences in social engagement and depressive symptoms between units can be ascribed to the composition of the resident population or to differences in type of care setting. METHODS: Thirty-seven long-term care units for residents with dementia in nursing- and residential homes in the Netherlands participated in the study. Social engagement and depressive symptoms were measured for 502 residents with the Minimum Data Set of the Resident Assessment Instrument. Results were analyzed using multilevel analysis. RESULTS: Residents of psychogeriatric units in nursing homes experienced low social engagement. Depressive symptoms were most often found in residents of psychogeriatric units in residential homes. Multilevel analyses showed that social engagement and depressive symptoms correlated moderately on the level of the units. This correlation disappeared when the characteristics of residents were taken into account. CONCLUSIONS: Social engagement and depressive symptoms are influenced not only by individual characteristics but also by the type of care setting in which residents live. However, in this study social engagement and depressive symptoms were not strongly related to each other, implying that separate interventions are needed to improve both outcomes.

Social well-being and its measurement in the nursing home, the SWON-scale.

AIMS AND OBJECTIVES: The aim of this study was to develop an observational scale to measure the social well-being of nursing home residents, by assessing not only the social behaviour of the resident towards others, but also the behaviour of others towards the resident. BACKGROUND: Traditionally, aspects of the social well-being of nursing home residents are assessed according to the social activities and interactions where they engage. Although these are important indicators of social well-being, other important indicators may include the positive social behaviour of others towards the resident (e.g. confirming the resident's behaviour or showing affection). DESIGN: A cross-sectional descriptive survey design. METHOD: From the perspective of human social needs, items relating to fulfillment of the needs for affection, behavioural confirmation and status were formulated and tested. This took place in three nursing homes in the Netherlands that provide somatic and psycho-geriatric care. RESULTS: The study (sample n = 306) yielded a short and reliable scale, the Social Well-being Of Nursing home residents-scale, with separate sub-scales (three items each) for fulfillment of the three social needs. CONCLUSIONS: These first results indicate that overall social well-being and its sub-dimensions can be measured with this new observational scale, although its validity needs to be confirmed. Including the social behaviour of others towards the resident may have provided a more comprehensive measure of the social well-being of nursing home residents. RELEVANCE TO CLINICAL PRACTICE: This measure may help to underscore the importance of the social behaviour of others (e.g. caregivers) for the overall social well-being of residents and with that assist care-providers in nursing homes to improve the social well-being of the residents.

Pain in European long-term care facilities: cross-national study in Finland, Italy and The Netherlands.

There have been very few and limited cross-national comparisons concerning pain among residents of long-term care facilities in Europe. The aim of the present cross-sectional study has been to document the prevalence of pain, its frequency and severity as well as its correlates in three European countries: Finland (north), Italy (south) and the Netherlands (western central). Patients (aged 65years or above) were assessed with the Minimum Data Set 2.0 (MDS).The final sample comprised 5761 patients from 64 facilities in Finland, 2295 patients from 8 facilities in the Netherlands and 1959 patients from 31 facilities in Italy. The prevalence of pain - defined as any type of pain - varied between 32% in Italy, 43% in the Netherlands and 57% in Finland. In nearly 50% of cases, pain was present daily; there were no significant differences in pain prevalence between patients with cancer diagnosis and those with non-cancer diagnosis. Regardless of the different prevalence estimates, pain was moderate-to-severe in over 50% of cases in all the countries. In multivariate logistic regression models, clinical correlates of pain were substantially similar across countries: pain was positively correlated with more severe physical disability (ADL impairment), clinical depression and a diagnosis of osteoporosis. Pain was negatively correlated with a diagnosis of dementia and more severe degrees of cognitive deterioration. We conclude that pain is frequently encountered in long-term care facilities in Europe and that, despite cultural and case-mix differences, pain speaks one language.

Depression in Dutch homes for the elderly: under-diagnosis in demented residents?

OBJECTIVE: Although community-based studies reported an increased incidence of depression among demented persons compared with non-demented persons, it is not clear whether this relationship also exists among institutionalised elderly persons. The aim of this study was to compare the prevalence of diagnosed depressive disorders and mood symptoms between demented and non-demented residents living in Dutch homes for the elderly. METHODS: Cross-sectional analysis in 16 homes for the elderly of routine outcome measurements by trained nurse assistants using the Resident Assessment Instrument (RAI) between January 2007 and April 2008. Nurse assistants recorded all known medical diagnoses including dementia and depression, as well as a structured observation of the presence or absence of 11 mood symptoms over the last 3 days. RESULTS: 313 demented and 463 non-demented residents with complete data were included (99% of all residents, mean age 84 years). 24.6% of participants were diagnosed with a depressive disorder, with no statistically significant difference between demented and non-demented persons (p = 0.237). Mood symptoms were more prevalent in demented residents (p < 0.001, OR 2.14, 95%CI 1.56-2.93). Among residents with mood symptoms, demented residents were less likely to be diagnosed with a depressive disorder than non-demented residents (p = 0.039, OR 0.61, 95%CI 0.38-0.98). CONCLUSIONS: The prevalence of diagnosed depressive disorders was comparable between demented and non-demented residents. However, demented residents suffered more from mood symptoms and may be at risk of under-diagnosis of depression.

Modifiable factors related to abusive behaviors in nursing home residents with dementia.

OBJECTIVES: To determine modifiable factors related to abusive behaviors in nursing home residents with dementia. DESIGN: Analysis of Minimum Data Set (MDS) of the Resident Assessment Instrument (RAI) information. SETTING: We used MDS-RAI data from 8 Dutch nursing homes and 10 residential homes that volunteered to collect data for care planning. We included the data of residents within a 12-month time window for each facility separately, resulting in a range from April 4, 2007, to December 1, 2008. PARTICIPANTS: We selected 929 residents older than 65 with Alzheimer's disease or other dementia who were dependent in decision making and not comatose. MEASUREMENTS: Cognitive Performance Scale, MDS Depression Scale and several individual items from the MDS-RAI (ability to understand others, verbally and physically abusive behavioral symptoms, resist care, diagnosis of Alzheimer's disease and of dementia other than Alzheimer's disease, diagnosis of depression, presence of delusions, hallucinations, pain frequency and constipation, and number of days receiving medications). RESULTS: Resistiveness to care, related to lack of understanding, depression, hallucinations and delusions, was strongly related to abusive behaviors. Presence of depressive symptoms and delusions was also related to abusive behaviors independent of resistiveness to care. Only very few residents who understood others and were not depressed were abusive. CONCLUSION: Abusive behaviors may develop from lack of understanding leading to resistiveness to care. Behavioral interventions preventing escalation of resistiveness to care into combative behavior and the treatment of depression can be expected to decrease or prevent abusive behavior of most nursing home residents with dementia.