[Coping strategies of older people with low mood]. / Omgaan met somberheid op oudere leeftijd: een kwalitatieve studie.

BACKGROUND: To gain new insights for support for older people with low mood, we explored the perceptions of 'screenpositive' older people on underlying causes and possible solutions. DESIGN AND METHOD: We conducted two in-depth interviews with 38 participants (≥77 years) who screened positive for depressive symptoms in general practice. To investigate the influence of the presence of complex health problems, we included 19 persons with and 19 without complex problems. Complex problems were defined as a combination of functional, somatic, psychological or social problems. RESULTS: All participants used several cognitive, social or practical coping strategies. Four patterns emerged: mastery, acceptance, ambivalence, and need for support. Some participants, especially those with complex problems, were ambivalent about possible interventions. CONCLUSION: Most older participants perceived their coping strategies as sufficient. General practitioners can support self-management by exploring the (effectiveness of) personal coping strategies, providing information, elaborating on perceptions of risks and discussing alternative options with older persons.

Older people coping with low mood: a qualitative study.

BACKGROUND: To gain new insight into support for older people with low mood, the perceptions, strategies, and needs of older people with depressive symptoms were explored. METHODS: Two in-depth interviews were held with 38 participants (aged ≥77 years) who screened positive for depressive symptoms in general practice. To investigate the influence of the presence of complex health problems, 19 persons with and 19 without complex problems were included. Complex problems were defined as a combination of functional, somatic, psychological or social problems. RESULTS: All participants used several cognitive, social or practical coping strategies. Four patterns emerged: mastery, acceptance, ambivalence, and need for support. Most participants felt they could deal with their feelings sufficiently, whereas a few participants with complex problems expressed a need for professional support. Some participants, especially those with complex problems, were ambivalent about possible interventions mainly because they feared putting their fragile balance at risk due to changes instigated by an intervention. CONCLUSION: Most older participants with depressive symptoms perceived their coping strategies to be sufficient. The general practitioners (GPs) can support self-management by talking about the (effectiveness of) personal coping strategies, elaborating on perceptions of risks, providing information, and discussing alternative options with older persons.

[Practice guideline 'Delirium' from the Dutch College of General Practitioners]. / NHG-standaard 'Delier'.

The revised practice guideline 'Delirium' of the Dutch College of General Practitioners (NHG) provides recommendations about the prevention, early detection, diagnosis and treatment of delirium in elderly patients in general practice. The guideline now also offers tools for the treatment of delirium in terminally-ill patients. A patient with delirium can only be cared for at home if a safe environment and the continuous presence of carers can be guaranteed. This requires close cooperation between the care services and the home carers involved and good coordination with the general practice health centre. The discharge from hospital of patients with persistent symptoms of delirium to their homes requires optimal transfer from the specialist/nursing staff to the general practitioner and home carers involved. The NHG guideline therefore pays considerable attention to collaboration and transfer in the care of patients with delirium. The revised version of this guideline was developed in close collaboration with the revision of the multidisciplinary guideline on delirium produced by the Dutch Order of Medical Specialists.

Quality of life in community-dwelling older persons with apathy.

OBJECTIVE: To investigate the relationship between apathy and perceived quality of life in groups both with and without depressive symptoms or cognitive impairment. METHODS: We conducted a cross-sectional study comparing quality of life in older persons with and without apathy in 19 Dutch general practices. Participants were 1,118 older persons aged at least 75 years without current treatment for depression and a Mini-Mental State Examination score of at least 19. Perceived quality of life was determined using Cantril's Ladder for overall quality of life, EuroQol (EQ)-5D thermometer for subjective health quality, and De Jong-Gierveld Loneliness questionnaire for perceived loneliness. Apathy was assessed with the Apathy Scale. RESULTS: Of the 1,118 older persons, apathy was present in 122 (11%) of them. Overall, apathy was associated with having no work, lower level of education, presence of depressive symptoms, cognitive impairment, and decreased scores on all quality of life measures. Among the 979 (88%) older persons without depressive symptoms and cognitive impairment, apathy was present in 73 (7.5%) of them, showing similar associations as in the total population. In the 77 (7%) persons with cognitive impairment only, apathy was correlated to a lower score on the EQ-5D thermometer. However, in the 51 (5%) depressed persons without cognitive impairment, presence of apathy did not contribute to their decreased quality of life. CONCLUSION: Apathy frequently occurred in community-dwelling older persons, also in the absence of depressive symptoms and cognitive impairment. In them, apathy contributed to the perception of a diminished quality of life in various aspects of daily life.

[Unambiguous practice guidelines on urinary tract infections in primary and secondary care]. / Eenduidige richtlijnen voor de eerste en tweede lijn inzake urineweginfecties.

The Dutch College of General Practitioners (NHG) practice guideline 'Urinary tract infections' intended for primary health care and the Dutch Working Party on Antibiotic Policy (SWAB) practice guideline 'Antimicrobial therapy in complicated urinary tract infections' intended for specialists in secondary care, were reviewed together. - In the NHG guideline the differentiation between 'complicated' and 'uncomplicated' urinary tract infections has been replaced by categorisation into age, sex, risk group and the presence of fever, or invasion of tissues.- If urinary tract infection has been diagnosed, a dip slide test can be used to determine resistance.- The guidelines recommend the most narrow-spectrum antibiotic to reduce further increase in antimicrobial resistance.- A chapter about women with recurrent urinary tract infections has been added to the SWAB guideline. Amongst other things, the chapter provides information on the prescription of prophylactic lactobacillus in secondary care.

GPs' perspectives on preventive care for older people: a focus group study.

BACKGROUND: Preventive care traditionally aims to prevent diseases or injuries. For older people, different aims of prevention, such as maintenance of independence and wellbeing, are increasingly important. AIM: To explore GPs' perspectives on preventive care for older people. DESIGN AND SETTING: Qualitative study comprising six focus groups with GPs in the Netherlands. METHOD: The focus-group discussions with 37 GPs were analysed using the framework analysis method. RESULTS: Whether or not to implement preventive care for older people depends on the patient's individual level of vitality, as perceived by the GP. For older people with a high level of vitality, GPs confine their role to standardised disease-oriented prevention on a patient's request; when the vitality levels in older people fall, the scope of preventive care shifts from prevention of disease to prevention of functional decline. For older, vulnerable people, GPs expect most benefit from a proactive, individualised approach, enabling them to live as independently as possible. Based on these perspectives, a conceptual model for preventive care was developed, which describes GPs' different perspectives toward older people who are vulnerable and those with high levels of vitality. It focuses on five main dimensions: aim of care (prevention of disease versus prevention of functional decline), concept of care (disease model versus functional model), initiator (older persons themselves versus GP), target groups (people with requests versus specified risk groups), and content of preventive care (mainly cardiovascular risk management versus functional decline). CONCLUSION: GPs' perspectives on preventive care are determined by their perception of the level of vitality of their older patients. Preventive care for older people with high levels of vitality may consist of a standardised disease-oriented approach; those who are vulnerable will need an individualised approach to prevent functional decline.

[Summary of the Dutch College of General Practitioners' practice guideline 'Depression']. / Samenvatting van de NHG-Standaard 'Depressie'.

This guideline gives recommendations for the management of depression and depressive symptoms. The diagnosis of suspected depression requires a broad exploration of symptoms, sometimes over several visits. The guideline promotes self-management and patient empowerment during the healing process. The initial step in the treatment of depressive symptoms is patient education; patients with depression are supported with activity scheduling and are offered a short course of psychological treatment. If the initial treatment in patients with depression is not effective or if the depression is associated with severe suffering, severe social dysfunctioning or severe psychiatric comorbidity, psychotherapy or an antidepressant is recommended.

Effects of a stepped-care intervention programme among older subjects who screened positive for depressive symptoms in general practice: the PROMODE randomised controlled trial.

OBJECTIVES: to determine (cost)-effectiveness of a stepped-care intervention programme among subjects ≥ 75 years who screened positive for depressive symptoms in general practice. DESIGN: the pragmatic cluster-randomised controlled trial with 12-month follow-up. SETTING: sixty-seven Dutch general practices. SUBJECTS: two hundred and thirty-nine subjects ≥ 75 years screened positive for untreated depressive symptoms (15-item Geriatric Depression Scale ≥ 5). METHODS: usual care (34 practices, 118 subjects) was compared with the stepped-care intervention (33 practices, 121 subjects) consisting of three steps: individual counselling; Coping with Depression course; and-if indicated-referral back to general practitioner to discuss further treatment. Measurements included severity of depressive symptoms [Montgomery-Åsberg Depression Rating Scale (MADRS)], quality of life, mortality and costs. RESULTS: at baseline subjects mostly were mildly/moderately depressed. At 6 months MADRS scores had improved more in the usual care than the intervention group (-2.9 versus -1.1 points, P=0.032), but not at 12 months (-3.1 versus -4.6, P=0.084). No significant differences were found within two separate age groups (75-79 years and ≥ 80 years). In intervention practices, 83% accepted referral to the stepped-care programme, and 19% accepted course participation. The control group appeared to have received more psychological care. CONCLUSIONS: among older subjects who screened positive for depressive symptoms, an offered stepped-care intervention programme was not (cost)-effective compared with usual care, possibly due to a low uptake of the course offer. TRIAL REGISTRATION: www.controlled-trials.com/ISRCTN 71142851v.

The influence of the administration method on scores of the 15-item Geriatric Depression Scale in old age.

Many rating scales can be self-administered or interviewer-administered, and the influence of administration method on scores is unclear. We aimed to study this influence on scores of the Geriatric Depression Scale (GDS-15), used as a screening instrument in general practice. In two general practices 376 registered patients aged 75 years and older were asked to participate. Exclusion criteria were dementia and current treatment for depression. The GDS-15 was administered twice within 1 month: self-administered by mail, and interviewer-administered during home visits. The sequence of administering the methods was different for the two practices. We analyzed differences in total and item GDS-scores. Of 141 subjects who participated (response rate 55%) 59 were men (42%). Mean age was 81.4 years (SD 4.8). When the GDS-15 was self-administered, 33 subjects (23.4%) left items unanswered. There were no items unanswered when the GDS-15 was interviewer-administered. On average the self-administered total GDS scores were 0.70 points higher than interviewer-administered scores (95% confidence interval=0.41; 0.98), with a large range of variation in the scores (limits of agreement -2.69 to 4.08). Item-item comparisons showed high percentages of agreement. Chance-corrected agreement (kappa) was moderate to fair, but three items showed only slight agreement (kappa values <0.21). In conclusion, compared to interviewer-administered scores, scores on the GDS-15 when self-administered were higher. The method of administration should be taken into account when interpreting scores.

Response to an unsolicited intervention offer to persons aged ≥ 75 years after screening positive for depressive symptoms: a qualitative study.

BACKGROUND: Screening can increase detection of clinically relevant depressive symptoms, but screen-positive persons are not necessarily willing to accept a subsequent unsolicited treatment offer. Our objective was to explore limiting and motivating factors in accepting an offer to join a "coping with depression" course, and perceived needs among persons aged ≥75 years who screened positive for depressive symptoms in general practice. METHODS: In a randomized controlled trial, in which 101 persons who had screened positive for depressive symptoms were offered a "coping with depression" course, a sample of 23 persons were interviewed, of whom five (22%) accepted the treatment offer. Interview transcripts were coded independently by two researchers. RESULTS: All five individuals who accepted a place on the course felt depressed and/or lonely and had positive expectations about the course. The main reasons for declining to join the course were: not feeling depressed, or having negative thoughts about the course effect, concerns about group participation, or about being too old to change and learn new things. Although perceived needs to relieve depressive symptoms largely matched the elements of the course, most of those who had been screened were not (yet) prepared to accept an intervention offer. Many expressed the need to discuss this treatment decision with their general practitioner. CONCLUSIONS: Although the unsolicited treatment offer closely matched the perceived needs of people screening positive for depressive symptoms, only those who combined feelings of being depressed or lonely with positive expectations about the offered course accepted it. Treatment should perhaps be more individually tailored to the patient's motivational stage towards change, a process in which general practitioners can play an important role.

Yield and costs of direct and stepped screening for depressive symptoms in subjects aged 75 years and over in general practice.

OBJECTIVE: To examine yield and costs of two screening methods for depressive symptoms in subjects ≥75 years in general practice. METHODS: In 73 general practices of 12.144 registered subjects ≥75 years 10.681 could be invited for screening. In the first 31 practices we invited 3797 subjects for direct screening which implied an invitation by letter followed by a home visit to administer the 15-item Geriatric Depression Scale (GDS-15). In the remaining 42 practices 6884 subjects were invited for stepped screening which implied that the GDS-15 was sent by post, followed by a home visit only if the self-administered GDS-15-score was ≥4 points. Being screen-positive for depressive symptoms was defined as an interviewer-administered GDS-15-score ≥5 points. Screening costs were estimated based on results in this study. RESULTS: Of all registered subjects 707 (5.8%) were already being treated for depression. The yield of direct screening was higher than of stepped screening (2.6% versus 1.9%, p = 0.009), with similar yields for subjects aged 75-79 years and for subjects aged ≥80 years. In a standard GP-practice with 160 subjects ≥75 years estimated total screening costs are about twice as high for direct screening than for stepped screening. Estimated costs per screen positive subject are €350 for direct screening and €250 for stepped screening. CONCLUSION: Direct screening has a higher yield, but is also more time consuming and more expensive. Whether the extra yield is clinically relevant and worth the extra costs, will depend on the subsequent treatment effect. TRIAL REGISTRATION: www.controlled-trials.com/ISRCTN 71142851

How usual is usual care in pragmatic intervention studies in primary care? An overview of recent trials.

BACKGROUND: Because pragmatic trials are performed to determine if an intervention can improve current practice, they often have a control group receiving 'usual care'. The behaviour of caregivers and patients in this control group should be influenced by the actions of researchers as little as possible. Guidelines for describing the composition and management of a usual care control group are lacking. AIM: To explore the variety of approaches to the usual care concept in pragmatic trials, and evaluate the influence of the study design on the behaviour of caregivers and patients in a usual care control group. DESIGN OF STUDY: Review of 73 pragmatic trials in primary care with a usual care control group published between January 2005 and December 2009 in the British Medical Journal, the British Journal of General Practice, and Family Practice. Outcome measures were: description of the factors influencing caregiver and patients in a usual care control group related to an individual randomised design versus cluster randomisation. RESULTS: In total, 38 individually randomised trials and 35 cluster randomised trials were included. In most trials, caregivers had the freedom to treat control patients according to their own insight; in two studies, treatment options were restricted. Although possible influences on the behaviour of control caregivers and control patients were more often identified in individually randomised trials, these influences were also present in cluster randomised trials. The description of instructions and information provided to the control group was often insufficient, which made evaluation of the trials difficult. CONCLUSION: Researchers in primary care medicine should carefully consider the design of a usual care control group, especially with regard to minimising the risk of study-induced behavioural change. It is recommended that an adequate description of the information is provided to control caregivers and control patients. A proposal is made for an extension to the CONSORT statement that requires authors to specify details of the usual care control group.

Subnormal vitamin B12 concentrations and anaemia in older people: a systematic review.

BACKGROUND: Pernicious anaemia is undeniably associated with vitamin B12 deficiency, but the association between subnormal vitamin B12 concentrations and anaemia in older people is unclear. The aim of this systematic review was to evaluate the association between subnormal vitamin B12 concentrations and anaemia in older people. METHODS: Clinical queries for aetiology and treatment in bibliographic databases (PubMed [01/1949-10/2009]; EMBASE [01/1980-10/2009]) were used. Reference lists were checked for additional relevant studies. Observational studies (> or =50 participants) and randomized placebo-controlled intervention trials (RCTs) were considered. RESULTS: 25 studies met the inclusion criteria. Twenty-one observational cross-sectional studies (total number of participants n = 16185) showed inconsistent results. In one longitudinal observational study, low vitamin B12 concentrations were not associated with an increased risk of anaemia (total n = 423). The 3 RCTs (total n = 210) were well-designed and showed no effect of vitamin B12 supplementation on haemoglobin concentrations during follow-up in subjects with subnormal vitamin B12 concentrations at the start of the study. Due to large clinical and methodological heterogeneity, statistical pooling of data was not performed. CONCLUSIONS: Evidence of a positive association between a subnormal serum vitamin B12 concentration and anaemia in older people is limited and inconclusive. Further well-designed studies are needed to determine whether subnormal vitamin B12 is a risk factor for anaemia in older people.

Co-occurrence of depression and anxiety in elderly subjects aged 90 years and its relationship with functional status, quality of life and mortality.

OBJECTIVE: To examine the prevalence of concurrent depression and anxiety and its relationship with functional status, quality of life and mortality in individuals at age 90. METHODS: In the Leiden 85-plus Study, a population based cohort study, depression (15-item Geriatric Depression Scale >or=5 points) and anxiety (Anxiety Screening Questionnaire >or=1 positive answer) were assessed in all 90-year old subjects with >or=19 points on the Mini Mental State Examination (MMSE). Functional status included: cognitive function (MMSE) and disability in activities of daily living (Groningen Activity Restriction Scale). Quality of life included: loneliness (Loneliness Scale of De Jong-Gierveld) and life satisfaction (Cantril's ladder). For all subjects mortality data were available up to a maximum age of 95.3 years. RESULTS: Of the subjects aged 90 years with MMSE >or=19 points (56 men, 145 women), 50 subjects (25%, 95% CI 19-31%) experienced depression and 25 subjects (12%, 95% CI 9-18%) anxiety; of them 34 (17%) experienced depression only, 9 (4%) anxiety only, and 16 (8%) both depression and anxiety. Presence of depression was associated with an overall decreased functional status and quality of life and with increased mortality. Within the depressed group, subjects with anxiety did not differ from subjects without anxiety, except for higher loneliness scores. CONCLUSION: Among individuals aged 90 years, depression and anxiety and their co-occurrence are highly prevalent. Anxiety does not add to poor functional status and increased mortality beyond that associated with depression, and is probably part of the phenomenology of depression in old age.