[Prevalence and prognostic importance of riskfactors for long hospital stay within elderly patients admitted to a hospital; a clinical-empirical study]. / Prevalentie en prognostisch belang van risicofactoren voor lange opnameduur onder ouderen bij ziekenhuisopname; een klinisch-empirische studie.

BACKGROUND: Of elderly patients (> 70 years) admitted to a general hospital 35% suffer from loss of self-care abilities compared to the level before admission. Risk of loss of self-care ability increases with age up to 65% after tthe age of 90. In addition, for many of these patients the duration of hospitalisation is relatively long. OBJECTIVE It is important to identify in an early stage frail-elderly patients who are at risk of a relatively long hospital stay. We conducted a study of the prevalence at intake (1st of 2nd admission day) of ten clinically relevant, patient-bound risk factors for a long hospital stay among 158 patients (> 60 years), acute and planned admitted to Vlietland Hospital. In addition, the prognostic value of the dichotomous risk factors for length of hospital stay was estimated as indicator of treatment complications. The ten clinically relevant risk factors were home care, history of falling, medication (> 4), weight loss, cognitive level and functioning, self-care, psychiatric symptoms, health status and quality of life. RESULTS: There was a high prevalence of risk factors; 47.5% of the elderly patients had four or more risk factors at intake. Home care and global cognitive deterioration were significant predictors of longer length of hospital stay. Furthermore, acute admission, weight loss, psychiatric symptoms and health status seemed important. The explained variance of the prognostic model was relatively small. CONCLUSION: The findings in this explorative-observational study showed a high prevalence of clinically relevant, patient-bound risk factors in elderly people in a general hospital. Some risk-factors were of prognostic interest for long hospital stay, although the explained variance was relatively small. This indicates that a more comprehensive study should be designed and conducted to include other patient-bound risk factors like co-morbidity, caregiver issues and social environment. Moreover, non-patient-bound factors should be addressed like intrinsic and logistic factors within the hospital, and the quality of recuperation programmes. Understanding of these factors contributes to timely identification of elderly patients, who are at high risk of a long hospital stay. Future policy is to perform specific treatment programmes for elderly patients identified as being patients at risk. Multidisciplinary person-oriented interventions and case management focussed on risk factors and functional recovery will be provided parallel and after hospital treatment period. Comprehensive scientific research on the cost-effectiveness of such a programme has started at the end of 200oo9 in Vlietland Hospital, Schiedam.

Benefits and pitfalls of pooling datasets from comparable observational studies: combining US and Dutch nursing home studies.

Different research groups sometimes carry out comparable studies. Combining the data can make it possible to address additional research questions, particularly for small observational studies such as those frequently seen in palliative care research. We present a systematic approach to pool individual subject data from observational studies that addresses differences in research design, illustrating the approach with two prospective observational studies on treatment and outcomes of lower respiratory tract infection in US and Dutch nursing home residents. Benefits of pooling individual subject data include enhanced statistical power, the ability to compare outcomes and validate models across sites or settings, and opportunities to develop new measures. In our pooled dataset, we were able to evaluate treatments and end-of-life decisions for comparable patients across settings, which suggested opportunities to improve care. In addition, greater variation in participants and treatments in the combined dataset allowed for subgroup analyses and interaction hypotheses, but required more complex analytic methods. Pitfalls included the large amount of time required for equating study procedures and variables and the need for additional funding.

[Prevalence of ulcers in Dutch nursing homes]. / Het vóórkomen van ulcera in verpleeghuizen.

INTRODUCTION: Earlier cross-sectional research in the Netherlands has found that one out of three nursing home patients has a pressure ulcer. The prevalence of other ulcers is unknown. METHODS: In eight nursing homes 2295 patients were assessed with the Minimum Data Set (MDS). The mean age of the patients was 82.9 years (SD 7.4) and 70% was female. One third had severe cognitive impairment and only 17% had no or little ADL impairment. RESULTS: Prevalence of pressure ulcers was: stage 1: 3,6%; stage 2: 2,5%; stage 3: 1,2%; stage 4: 0,8%. Having a pressure ulcer was strongly correlated with ADL dependency: Odds Ratio (OR) 8,4 for moderate ADL-dependency, and OR 35,4 for severe ADL-dependency. Patients with pressure ulcers had more often pain (OR 2,7) and depressive symptoms (OR 2,1). Bowel incontinence was significantly correlated (OR 2,6) with pressure ulcers, just as the presence of an indwelling catheter (OR 3,2) and the use of diapers (OR 2,2), but urinary incontinence was not correlated with pressure ulcers. The prevalence of a venous ulcers was 2,6% and 1,7% had a venous ulcer higher than stage 1. The combination of foot ulcers and diabetes occurred in 1,2%, the combination of a peripheral vascular disease and ulcers in only 0,7%. The use of pressure reducing interventions increased with ADL dependency, nevertheless only 44% of the very dependent patients used these interventions.

The MDS Challenging Behavior Profile for long-term care.

The objective was to construct a reliable and valid challenging behavior scale with items from the Minimum Data Set (MDS). Exploratory factor analyses of a sample of 656 nursing home residents yielded a 16-item Behavior Profile containing four internally consistent and valid subscales measuring conflict behavior, withdrawn behavior, agitation and attention seeking behavior (alpha range: 0.69-0.80). On a second dataset of 227 nursing home residents, internal consistency, inter-rater reliability and validity against the Behavior Rating Scale for Psychogeriatric Inpatients (GIP) were established. Internal consistency of the subscales ranged between 0.54 and 0.78. The overall inter-rater reliability of the items was 0.53 (kappa); of the scale it was 0.75 (ICC). The MDS Challenging Behavior Profile could potentially be an important contribution to existing clinical MDS-scales but additional studies on reliability, validity and usefulness are needed.

[Palliative care and the health care for the elderly]. / Palliatieve zorg en de geneeskunde voor ouderen.

Concentrating on diagnosing the disease for which often little can be done, can lead to ignoring or underplaying symptoms or disabilities for which often much can be done.

[The end of life in Dutch nursing homes]. / Het levenseinde in Nederlandse verpleeghuizen.

BACKGROUND: Nursing homes (NH) are less well studied than hospices or hospitals as a setting for terminal care. The aim of this study is to identify the direct causes and underlying diseases of the terminal phase in Dutch nursing homes. METHODS: A prospective study of terminally ill patients with a maximum life-expectancy of (less than) 6 weeks in 16 NHs in the Netherlands. 544 long-term care patients were enrolled in the study. RESULTS: The terminal phase was marked with symptoms of low fluid and food intake, general weakness and respiratory problems/dyspnea. Direct causes of these conditions were diseases of the respiratory system (mainly pneumonia), and general disorders, e.g., cachexia. Mental and behavioral disorders and diseases of the circulatory system were the two main underlying diseases of the terminal phase. Per 100 beds per year, 34 NH patients entered a terminal phase. Most patients (82.9%) died within seven days of inclusion. End-of-life decisions occurred in 70% of all deceased patients, most often made on the psycho-geriatric wards. CONCLUSIONS: Providing good and timely palliative care to elderly patients in Dutch nursing homes is a major medical and societal challenge. In this study, the terminal phase of the mainly non-cancer patients is difficult to predict, and once diagnosed, little time is left.

[Pneumonia mortality risk in patients with dementia: nursing home physicians' use and evaluation of a prognostic score]. / Kans op overlijden aan een pneumonie van patiënten met dementie: gebruik en beoordeling van een prognostische score door verpleeghuisartsen.

A validated prognostic score for mortality risk 14 days after antibiotics treatment of nursing home residents with dementia and pneumonia is available. Of the nursing homes contacted, 96% was prepared to participate in a clinical impact analysis to examine usefulness of the score in practice. After randomising nursing homes, physicians of 27 homes in the intervention group were asked to complete a questionnaire and use the score for the next case of pneumonia; the control group comprised physicians of the 27 other homes who only completed the questionnaire. The 38 respondents from the control group who all reported about a single patient did not differ from the respondents of the intervention group (31 physicians enrolled 34 patients). Only in 24 cases did physicians calculate the score. For 79% of those patients, the score was (at least somewhat) useful, but mostly to train prognostication competencies and for better documentation of prognosis; frequently treatment decisions had already been made. Of the total group of respondents, the majority was positive about the use of prognostic scores in general, but no-one in the participating homes had any experience with it. The prognostic score is potentially useful for an important group of patients with pneumonia, but further implementation research and inclusion of prognostic instruments in training curricula is needed.

[Evaluation of units for short-term terminal care in nursing homes]. / Evaluatie van units voor kortdurende terminale zorg bij verpleeghuizen.

The Units for short-term terminal care in 10 nursing homes were evaluated in terms of (a) meeting minimum care requirements for organisation, personnel and expertise and (b) changes in outcomes in patients. Interview with staff members show that 69% of the care requirements were met. Requirements for expertise development were better met (77%), and requirements for personnel and team were met less well (58%). The studies on patient outcomes show that the patients' functional status decreased as death approached, but symptoms did not decrease with similar rates. In addition, quality of life remained stable. We conclude that the minimum care requirements should be revised, taken into account the way the requirements are used in daily practise. The data seem to point at good quality of care. We advise a repetition of the last evaluation in 2003.

Self report on quality of life in dementia with modified COOP/WONCA charts.

This study investigates whether a modified version of the COOP/WONCA charts is suitable to assess quality of life (QOL) in persons with dementia in nursing homes. A group of 112 institutionalized persons with moderate to severe dementia were approached for an interview. Twenty-two were observed not to be communicative, leaving 90. Sixty-seven persons were able to answer four out of six questions adequately (interviewable). Inter-observer reliability (n=38) was excellent (weighted kappa 0.90 to 0.97). Test-retest reliability (n=34; one week interval) ranged from poor for Daily and Social Activities and for the QOL charts, to moderate for Feelings and Pain, and satisfactory for Physical Functioning (weighted kappa 0.23 to 0.67). Interviewability was associated with severity of the dementia and communication ability. Support for convergent validity was found in medium-sized Spearman correlations between the COOP/WONCA charts and related variables. Support for discriminant validity was found in the absence of association between the Ccharts and non-related variables. The modified COOP/WONCA charts can be used to assess QOL in 60% of people with dementia in nursing homes but further modification is needed. Severe cognitive impairment and communication disabilities proved limiting factors for the use of the instrument. Although the illustrations on the charts appeared not to be helpful, the written response options in addition to verbal presentation proved useful during the administration of the charts.

Dementia severity, decline and improvement after a lower respiratory tract infection.

OBJECTIVE: To assess decline and improvement in functional characteristics, cognition and restraint use after a lower respiratory tract infection (LRI) and describe variation by dementia severity. DESIGN: Two prospective cohort studies. SETTING: Nursing homes in the Netherlands and in Missouri, USA. PARTICIPANTS: 227 Dutch and 396 Missouri nursing home residents with dementia and LRI who were treated with antibiotics. MEASUREMENTS: We compared functional characteristics (Activities of Daily Living [ADL], bedfast status, pressure ulcers, incontinence), cognition and restraint use 3 months after an LRI with status 1 to 2 weeks before diagnosis. RESULTS: Residents with LRI frequently declined on all measures, but many also improved, including those with severe dementia. On the measures where residents could still decline further, residents with severe dementia showed higher variability than residents with less severe dementia. This was most obvious for bedfast status and restraint use. CONCLUSIONS: Compared with less severely demented residents, residents with severe dementia showed more decline on measures where they still had room for change. However, on these measures, residents with severe dementia also improved more often. LRI does not necessarily lead to deterioration even in individuals with severe dementia.

[Psychiatric function disorders: association with cognitive function, activities of daily living and biographical data]. / De relatie van psychiatrische functiestoornissen met cognitie, activiteiten dagelijks leven (ADL) en biografische gegevens. Een replicatie-onderzoek op een polikliniek voor cognitieve functiestoornissen.

BACKGROUND: The prevalence of non-cognitive, psychiatric function disorders (PFD) in psychogeriatric patients, staying in a nursing home is high; it varies from 70 to 8%. It has a negative impact on the quality of life and life-expectancy. It affects caregiver distress and is an important predictor of permanent admission to an institution. In addition the PFD has predictive potentialities for discharge from reactivation programmes and survival. Although there is a relationship between PFD (measured by NPI) and cognitive function disorders it has to be stated explicitly that from psychiatric point of view these two entities have to be distinguished. This distinction, already been studied by this research group, needed to be replicated in another population. OBJECTIVE is to estimate 1) to which degree the prevalence of PFD in psychogeriatric patients, referred to a policlinics for cognitive function disorders (Index condition), differs from community dwelling psychogeriatric patients at referral to clinical and transmural nursing home programmes (Reference condition); 2) to which degree PFD is associated with both cognitive function disorders, activities of daily living for the two conditions; 3) to which degree PFD is associated with relevant general details of the patient, particularly gender, age and marital status, for the two conditions. METHODS: In the Index condition particated patients aged > or = 65 years suffering from cognitive function disorders (N=70) who were referred to a policlinic for cognitive function disorders who were suspected to suffer from psychiatric function disorders. For 35 patients of them complete data on NPI, MMSE en Barthel Index (BI) were available. In the Reference condition participated patients (age 2> or = 65), who were referred to clinical and transmural nursing home programmes and who suffered from cognitive function disorders (MMSE < 29) (N=487). For 385 patients of them all data on NPI, MMSE and BI were available. RESULTS: Of all patients 92% suffered from at least one NPI symptom; 82% from two or more. Depression, Apathy, Anxiety and Irritability had high prevalences in the two samples. Application of logistic regression analysis for the prediction of total as well as individual NPI-symptoms showed that the prognostic potentialities of MMSE, BI and biographic data were very limited (R(2) = 0.11; max.). The non-metric princal component analysis and confirmatory factor analysis of NPI, MMSE and BI for the two samples, showed that MMSE and BI loaded highly on the dimension 'Cognition' and NPI on the dimension 'Psychiatric function disorders'. The dimensional structure of the two samples did not show significant differences. CONCLUSION: The dimensional structure of the Index condition highly corresponded to the Reference condition; that is to say that the PFD appeared to be relatively independent of cognition and ADL. High prevalences of PFD (NPI), the broad variance of NPI-symptoms and the limited prognostic importance of MMSE, BI and general details for total NPI-score as well as individual NPI-symptoms were confirmed in both conditions. The dimension 'Psychiatric function disorder' was relative independent of the dimension 'Cognition'. As a result it is of clinical interest - in case of referral to clinical and transmural programmes - to distinguish the psychiatric dimension from the cognitive dimension.

[Treatment of pneumonia in nursing home residents with severe dementia: for residents with poor prognosis, a more reserved approach in The Netherlands and more active treatment in the United States]. / Behandeling van pneumonie bij verpleeghuispatiënten met ernstige dementie: terughoudender beleid in Nederland en actiever beleid in de verenigde Staten naarmate de prognose ongunstiger is.

OBJECTIVE: To describe differences in the treatment of pneumonia and in the association of treatment with prognosis in Dutch and American nursing home patients with late-stage dementia. Design. Prospective studies in The Netherlands and the American state of Missouri. METHOD: In 61 Dutch nursing homes and 36 in Missouri, severely demented patients with pneumonia were included in the periods October 1996-July 1998 and August 1995-September 1998 respectively. Data was collected on their state of health, comorbidity, symptoms of pneumonia and treatment aspects such as antibiotic use, hospital admission and relief of symptoms. Comparisons were made between treatments in both countries and between groups of patients with a similar probability of mortality within 2 weeks. RESULTS: A total of 328 Dutch and 280 American patients were selected. Antibiotics were more frequently withheld in The Netherlands (in 33% of patients) than in Missouri (24%). Differences in antibiotic use were more pronounced in patients with a poor prognosis (56% versus 15%). Dutch patients were more frequently dehydrated but were less likely to receive rehydration therapy than American patients, with a larger difference in patients with a poor prognosis (2% versus 63%). Treatments to relieve symptoms that were provided more often in patients with a poor prognosis (in 20-26%) were: oxygen (both countries), and in The Netherlands also opiates, and hypnotics, sedatives or anxiolytics. CONCLUSION: In The Netherlands, curative treatment was frequently withheld in patients with severe dementia and pneumonia, and even more frequently when the prognosis was poorer. Conversely, treatment in Missouri was more active in patients with a poor prognosis. Despite more frequent palliative treatment goals in The Netherlands, treatments to relieve symptoms were provided infrequently and inconsistent with this approach. These insights may be helpful for decision-making in the treatment of pneumonia in patients with severe dementia.

[A cross-cultural study of physician treatment decisions in relation to demented nursing home patients who develop pneumonia]. / Een cultuurvergelijkend onderzoek naar behandelbesluiten van artsen met betrekking tot demente verpleeghuispatiënten met pneumonie.

This qualitative interview study in The Netherlands and North Carolina (US) found that physician treatment decisions are influenced by contextual differences in physician training and healthcare delivery in the US and The Netherlands. Dutch physicians treating nursing home residents with dementia and pneumonia assumed active, primary responsibility for treatment decisions while US physicians were more passive and deferential to family preferences, even in cases where they considered the families' wishes inappropriate. Dutch physicians knew their patients well and made treatment decisions based on what they perceived was in the best interest of the patient while US physicians reported limited knowledge of their nursing home patients due to a lack of contact time. Efforts to improve care for patients with poor quality of life who lack decision-making capacity must consider the context of societal values, physician training, and the processes by which physicians negotiate patient and family preferences.

The availability of allied health care in nursing homes.

PURPOSE: To determine the availability of allied health care in nursing homes in the Netherlands, and its dependency on characteristics of the nursing home. METHODS: Structured surveys by telephone were carried out in a sample of 100 from a country total of 286 somatic (for somatic patients only) and combined (with units for both somatic and psychogeriatric patients) nursing homes. Multiple linear regression analyses were performed to determine relationships between the availability of care and the type of nursing home, its country location (urban/non-urban) and the presence of specific wards/units within the nursing home. RESULTS: Physiotherapy and occupational therapy were present in almost all nursing homes (99% and 93% respectively); 92% of the nursing homes offered speech- and language therapy and 88% had dietetics available. Average availability rates were: 2.16 full time equivalents per 100 beds/places for physiotherapy, 0.96 for occupational therapy, 0.38 for speech- and language therapy and 0.18 for dietetics. Somatic nursing homes and nursing homes with stroke-units, day-care, or outpatient care present, had higher availability rates on allied health care. CONCLUSIONS: Allied health care disciplines varied in terms of full-time equivalents per 100 beds/places. Per discipline also a wide variation exists in full-time equivalents per 100 beds/places among all participating nursing homes, regardless of their type. Characteristics of nursing homes had small effects on availability rates. International research is recommended in order to compare data and eventually reach consensus on optimal availability rates of allied health care in nursing homes, tuned to the demand.

Construction and validation of a patient- and user-friendly nursing home version of the Geriatric Depression Scale.

OBJECTIVE: To construct a patient- and user-friendly shortened version of the Geriatric Depression Scale (GDS) that is especially suitable for nursing home patients. METHODS: The study was carried out on two different data bases including 23 Dutch nursing homes. Data on the GDS (n = 410), the Mini Mental State Examination (n = 410) and a diagnostic interview (SCAN; n = 333), were collected by trained clinicians. Firstly, the items of the GDS-15 were judged on their clinical applicability by three clinical experts. Subsequently, items that were identified as unsuitable were removed using the data of the Assess project (n = 77), and internal consistency was calculated. Secondly, with respect to criterion validity (sensitivity, specitivity, area under ROC and positive and negative predictive values), the newly constructed shortened GDS was validated in the AGED data set (n = 333), using DSM-IV diagnosis for depression as measured by the SCAN as 'gold standard'. RESULTS: The eight-item GDS that resulted from stage 1 showed good internal consistency in both the Assess data set (alpha = 0.86) and the AGED dataset (alpha = 0.80). In the AGED dataset, high sensitivity rates of 96.3% for major depression and 83.0% for minor depression were found, with a specificity rate of 71.7% at a cut-off point of 2/3. CONCLUSION: The GDS-8 has good psychometric properties. Given that the GDS-8 is less burdening for the patient, more comfortable to use and less time consuming, it may be a more feasible screening test for the frail nursing home population.

Cardiovascular risk factors in cognitively impaired nursing home patients: a relationship with pain?

Cardiovascular risk factors (CRF) such as hypertension and diabetes mellitus favour the development of both vascular dementia (VaD) and Alzheimer's disease (AD). The resulting deafferentation may increase the experience of pain in VaD and in AD. The goal of the present study was to examine the relationship between CRF and pain in a sample of 107 cognitively impaired nursing home patients who had also a chronic pain condition. The prevalence of pain in patients with hypertension or diabetes mellitus was higher (25/41=61% of them had pain) than those without diabetes or hypertension (of whom 24/66=36.4% had pain, p=0.017). In a multivariate logistic regression model (adjusted for gender, age and depression) the presence of diabetes or hypertension was a risk indicator for pain: odds ratio: 3.48, p=0.005, 95% CI: 1.45-8.38. This finding supports the hypothesis that as a result of CRF, disruptions of cortico-cortico and cortico-subcortical pathways occur, and consequently, enhances pain in this group of patients.

[Dying with dementia: what do we know about it?]. / Sterven met dementie: wat weten wij ervan?

Death with dementia is increasingly common, yet research on end of life with dementia and end-of-life care for such patients has been sparse. This article reviews recent studies in this area, most of which were done in US nursing homes. Research focused on five domains: prognosis, decision making, treatment, patient's health and suffering, and family's circumstances and satisfaction with care. Prognostication focused on developing risk scores for mortality within 6 months or a year, and while decision making was usually studied qualitatively, the other three domains were largely covered by a series of small, retrospective studies. Future direction in research is discussed, including the ongoing CASCADE project in Boston and the Dutch End of Life with Dementia Study (DEOLD). Both of these prospective studies in nursing home residents assess decision making, as well as factors associated with family's satisfaction and patient suffering. These studies will provide insight into interventions that are most likely to improve end of life care of patients with dementia in the respective countries and elsewhere.

[The GDS-8; a short, client- and user-friendly shortened version of the Geriatric Depression Scale for nursing homes]. / De GDS-8: een korte, cliënt- en gebruikersvriendelijke versie van de Geriatrische depressie Schaal voor verpleeghuizen.

The objective of this study was to construct a patient- and user-friendly shortened version of the Geriatric Depression Scale (GDS) that is especially suitable for nursing home patients. The study was carried out on two different data bases including 23 Dutch nursing homes. Data on the GDS (n=410), the Mini Mental State Examination (n=410) and a diagnostic interview (SCAN; n=333), were collected by trained clinicians. Firstly, the items of the GDS-15 were judged on their clinical applicability by three clinical experts. Subsequently, seven items that were identified as unsuitable were removed using the GDS-data of the Assess-project (n=77), and internal consistency was calculated. Secondly, with respect to criterion validity (sensitivity, specificity, area under ROC and positive and negative predictive values), the newly constructed 8-item version of the GDS was validated in the AGED data set (n=333), using DSM-IV diagnosis for depression as measured by the SCAN as 'gold standard'. In the AGED dataset, the GDS-8 was internally consistent (alpha=.80) and high sensitivity rates of 96.3% for major depression and 83.0% for minor depression were found, with a specificity rate of 71.7% at a cut-off point of 2/3. The GDS-8 has good psychometric properties. Given that the GDS-8 is less burdening for the patient, more comfortable to use and less time consuming, it may be a more feasible screening test for the frail nursing home population.