Effect of the Care Programme for the Last Days of Life (CAREFuL) on satisfaction with care as perceived by family caregivers and geriatric nurses. A qualitative implementation study.

BACKGROUND: The CAREFuL programme based on the Liverpool Care Pathway showed improvements in end-of-life care for patients dying in acute geriatric hospital wards. Importantly, it did not show positive effects on families' satisfaction with care. OBJECTIVES: To gain insight into reasons for absent improved families' satisfaction with care to make adaptations to CAREFuL. METHODS: We planned a two-step implementation, this study reports the first step. We implemented CAREFuL as tested in the cluster RCT with extra attention to families' involvement, in 6 hospitals. We performed semi-structured interviews with family caregivers (n = 11) and geriatric nurses (n = 11) to ask about their experiences with CAREFuL. We used Nvivo12. RESULTS: This study showed overall positive experiences. Family caregivers were satisfied by seeing their relative being comfortable, and by knowing whom to go to. A shared care approach within the team made nurses comfortable for entering the room. However, families did not always know the rationale for specific actions (e.g. cessation of nutrition) and some wanted to be involved more in the care of their relative. They often had to take initiative for receiving information. Finally, supporting leaflets were not always given or were given without any explanation. DISCUSSION: We made adaptations to CAREFuL to improve families' satisfaction with care. A trigger sentence is added to support nurses in communicating with families. Professionals need to give a rationale for (not) doing specific actions. Leaflets can be used only as a support for direct communication. This adapted programme will be implemented in another 20 wards.

Diagnosing COVID-19; towards a feasible COVID-19 rule-out protocol.

INTRODUCTION: We present the results of the COVID-19 rule-out protocol at Ghent University Hospital, a step-wise testing approach which included repeat NFS SARS-CoV-2 rRT-PCR, respiratory multiplex RT-PCR, low-dose chest CT and bronchoscopy with BAL to confirm or rule-out SARS-CoV-2 infection in patients admitted with symptoms suggestive of COVID-19. RESULTS: Between 19 March 2020 and 30 April 2020, 455 non-critically ill patients with symptoms suspect for COVID-19 were admitted. The initial NFS for SARS-CoV-2 rRT-PCR yielded 66.9%, the second NFS 25.4% and bronchoscopy with BAL 5.9% of total COVID-19 diagnoses. In the BAL fluid, other respiratory pathogens were detected in 65% (13/20) of the COVID-19 negative patients and only in 1/7 COVID-19 positive patients. Retrospective antibody testing at the time around BAL sampling showed a positive IgA or IgG in 42.9 % of the COVID-19 positive and 10.5% of the COVID-19 negative group. Follow-up serology showed 100% COVID-19 positivity in the COVID-19 positive group and 100% IgG negativity in the COVID-19 negative group. CONCLUSION: In our experience, bronchoscopy with BAL can have an added value to rule-in or rule-out COVID-19 in patients with clinical and radiographical high-likelihood of COVID-19 and repeated negative NFS testing. Furthermore, culture and respiratory multiplex PCR on BAL fluid can aid to identify alternative microbial etiological agents in this group. Retrospective analysis of antibody development in this selected group of patients suggests that the implementation of serological assays in the routine testing protocol will decrease the need for invasive procedures like bronchoscopy.

Factors associated with costs of care in community-dwelling persons with dementia from a third party payer and societal perspective: a cross-sectional study.

BACKGROUND: Besides the importance of estimating the global economic impact of care for persons with dementia, there is an emerging need to identify the key factors associated with this cost. The aim of this study was to analyze associations between the cost of care in community-dwelling persons with dementia and caregiver characteristics from both the healthcare third party payer perspective and the societal perspective. METHODS: Several characteristics based on the cross-sectional data of 355 dyads of informal caregivers and persons with dementia living in Belgium were identified to include in a log-gamma generalized linear model and were used in a multiple linear regression model with bootstrapping to test robustness. RESULTS: The mean monthly cost of care for a community-dwelling person with dementia was estimated at € 2339 (95% CI € 2133 - € 2545) per person from a societal perspective and at € 968 (95% CI € 825 - € 1111) per person from a third party payer viewpoint. Informal care accounted for the majority of the monthly costs from the societal perspective. Community based healthcare resource use represented the largest cost from the third party perspective. According to the regression analyses, a higher level of functional dependency of the person with dementia and a higher educational level of the caregiver were associated with a higher monthly cost from both a third party payer perspective and a societal perspective. In addition, being retired and a higher quality of life in the caregivers were associated with a lower monthly cost of care from the societal perspective. CONCLUSIONS: Several characteristics of the caregiver and the person with dementia were associated with the monthly costs of care from a third party payer and a societal perspective. Despite the lack of clear causal relationships, the results of this study can assist policy makers in planning and financing future dementia care. TRIAL REGISTRATION: Clinicaltrials.gov NCT02630446, December 15, 2015.

Methicillin-resistant staphylococcus aureus pneumonia in older people: a diagnostic and therapeutic challenge.

Pneumonia is one of the leading causes of death in older people, with high mortality rates (> 80%). One of the bacterial pathogens causing pneumonia is Staphylococcus aureus. The unique adaptive ability of S. aureus to a broad range of antibiotics has led to the emergence of methicillin-resistant S. aureus (MRSA) strain. MRSA pneumonia remains a relatively uncommon infection in older people, but it is associated with a very high mortality rate. We report two cases of MRSA pneumonia that highlight the severe clinical presentation and virulence of MRSA infections in geriatric population. MRSA pneumonia can present with mostly an uncontrollable clinical evolution and an infaust prognosis. Therefore, clinicians should be aware of MRSA pneumonia in patients with comorbidities, recent hospitalization with antibiotic treatment, previous MRSA infections and also in patients residing in nursing homes/revalidation centers. Low prevalence of MRSA combined with a lack of highly distinctive clinical features makes accurate targeting of empirical treatment with antibiotics very difficult. Currently, monotherapy with linezolid or vancomycin remain the first choice, in adult patients with proven MRSA infection. Despite the higher age related mortality rates, there are no specific treatment guidelines for older patients.

Increasing use of cognitive measures in the operational definition of frailty-A systematic review.

Ageing is associated both with frailty and cognitive decline. The quest for a unifying approach has led to a new concept: cognitive frailty. This systematic review explores the contribution of cognitive assessment in frailty operationalization. PubMed, Web of Knowledge and PsycINFO were searched until December 2016 using the keywords aged; frail elderly; aged, 80 and over; frailty; diagnosis; risk assessment and classification, yielding 2863 hits. Seventy-nine articles were included, describing 94 frailty instruments. Two instruments were not sufficiently specified and excluded. 46% of the identified frailty instruments included cognition. Of these, 85% were published after 2010, with a significant difference for publication date (X2 = 8.45, p < .05), indicating increasing awareness of the contribution of cognitive deficits to functional decline. This review identified 7 methods of cognitive assessment: dementia as co-morbidity; objective cognitive-screening instruments; self-reported; specific signs and symptoms; delirium/clouding of consciousness; non-specific cognitive terms and mixed assessments. Although cognitive assessment has been increasingly integrated in recently published frailty instruments, this has been heterogeneously operationalized. Once the domains most strongly linked to functional decline will have been identified and operationalized, this will be the groundwork for the identification of reversible components, and for the development of preventive interventional strategies.

[Tiredness of life in older adults]. / Vieillesse et fatigue de vivre. La lassitude chez la personne âgée.

Tiredness of life in older adults can lead to a request for the wish to die. This article provides a practical approach for physicians of this problem on the basis of a flow chart. The main causes of tiredness of life should be identified and evaluated for their reversibility and treatment options. The first group are the physical factors which, besides organ pathology, should also take frailty into account as a possible cause. A second important group are the psychological risk factors such as psychiatric disorders, loneliness, dignity, subjective well-being, coping and spiritual power. These factors also determine the complaint and needs of the patient. Here is a multidisciplinary assessment and approach desirable. This multidisciplinary approach also applies to the socioeconomic risk factors. In addition, the caregiver should examine if the weariness of life indeed gives rise to the suffering of the older person and to what extent this is hopeless and unbearable suffering. Hopelessness is a professional judgment about the remaining treatment and care perspective and is often objectified; unbearable is a matter of the patient and therefore always subjective and personal. The current legislation on euthanasia, the reversibility of the underlying causes and the unbearable suffering will determine whether the request of the patient with tiredness of life can be considered. Some questions will not fit within the proposed framework. For those a multidisciplinary advice of an ethics committee may be desirable.

La fatigue de vie chez la personne âgée peut susciter le désir de mourir. Ce document, destiné aux médecins, est un manuel pratique sur cette problématique. Il faut rechercher les facteurs de risque physiques, psychiques et socioéconomiques de la lassitude pour évaluer dans quelle mesure ils sont réversibles et peuvent être traités. L'étiologie de la lassitude étant souvent multifactorielle, il est souhaitable que son évaluation soit multidisciplinaire, tout comme son approche. Le prestataire de soins doit chercher à savoir si la lassitude est responsable d'une souffrance sans issue et insupportable. Le fait que la souffrance soit sans issue doit être évalué de manière professionnelle pour répondre à la question de savoir si une perspective de traitement et de soins est encore présente, ce qui est souvent objectivable. Le fait que la souffrance soit insupportable est strictement personnel et toujours subjectif. L'éventuelle prise en compte d'une demande d'euthanasie en cas de fatigue de vivre est déterminée par les critères de la législation actuelle sur l'euthanasie, la réversibilité des causes sous-jacentes de la lassitude et le caractère insupportable de la souffrance. Si, comme cela arrive de temps à autre, la demande d'euthanasie se situe en dehors du cadre proposé, l'avis multidisciplinaire mûrement réfléchi d'un comité d'éthique est alors souhaitable.

Balancing truth-telling: relatives acting as translators for older adult cancer patients of Turkish or northwest African origin in Belgium.

The first generation of Turkish and Northwest African immigrants in Belgium are ageing and at risk for developing cancer. Relatives play an important role and provide both emotional and practical care, including mental support and acting as a contact person and/or a translator for improving access to healthcare, as most patients and their spouses have only a limited command of the language. Although access to professional interpreters has shown to be the best guarantee for qualitative healthcare, oncology health providers working with relatives as interpreters is much more common than professional interpreters. The aim of this study was to provide insight into the process wherein relatives balance truth-telling in translating for an older family member diagnosed with cancer. This was a qualitative research study, with elements of constructivist grounded theory. Twenty-eight loosely structured interviews were conducted. Most relatives consider it their responsibility to contribute to a positive attitude of the patient. Relatives decided to what extent they inform the patient, based on several motives and embedded in their assessment of the patient's emotional strength, understanding and need to be informed. What they decide influences the way they act as a translator and/or a contact person between the patient and health professional(s). Some considered it best to omit medical information while others considered it best to inform the patient fully. The results emphasise the importance for healthcare providers to take into account the complexity and unpredictable character of the process of balancing truth-telling when family members translate for their ill older relative.

A qualitative exploration of the collaborative working between palliative care and geriatric medicine: Barriers and facilitators from a European perspective.

BACKGROUND: With an increasing number of people dying in old age, collaboration between palliative care and geriatric medicine is increasingly being advocated in order to promote better health and health care for the increasing number of older people. The aim of this study is to identify barriers and facilitators and good practice examples of collaboration and integration between palliative care and geriatric medicine from a European perspective. METHODS: Four semi-structured group interviews were undertaken with 32 participants from 18 countries worldwide. Participants were both clinicians (geriatricians, GPs, palliative care specialists) and academic researchers. The interviews were transcribed and independent analyses performed by two researchers who then reached consensus. RESULTS: Limited knowledge and understanding of what the other discipline offers, a lack of common practice and a lack of communication between disciplines and settings were considered as barriers for collaboration between palliative care and geriatric medicine. Multidisciplinary team working, integration, strong leadership and recognition of both disciplines as specialties were considered as facilitators of collaborative working. Whilst there are instances of close clinical working between disciplines, examples of strategic collaboration in education and policy were more limited. CONCLUSIONS: Improving knowledge about its principles and acquainting basic palliative care skills appears mandatory for geriatricians and other health care professionals. In addition, establishing more academic chairs is seen as a priority in order to develop more education and development at the intersection of palliative care and geriatric medicine.

European palliative care guidelines: how well do they meet the needs of people with impaired cognition?

OBJECTIVE: Numbers of people dying with cognitive impairment (intellectual disability (ID), dementia or delirium) are increasing. We aimed to examine a range of European national palliative care guidelines to determine if, and how well, pain detection and management for people dying with impaired cognition are covered. METHODS: Questionnaires were sent to 14 country representatives of the European Pain and Impaired Cognition (PAIC) network who identified key national palliative care guidelines. Data was collected on guideline content: inclusion of advice on pain management, whether cognitively impaired populations were mentioned, assessment tools and management strategies recommended. Quality of guideline development was assessed with the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. RESULTS: 11 countries identified palliative care guidelines, 10 of which mentioned pain management in general. Of these, seven mentioned cognitive impairment (3 dementia, 2 ID and 4 delirium). Half of guidelines recommended the use of pain tools for people with cognitive impairment; recommended tools were not all validated for the target populations. Guidelines from the UK, the Netherlands and Finland included most information on pain management and detection in impaired cognition. Guidelines from Iceland, Norway and Spain scored most highly on AGREE rating in terms of developmental quality. CONCLUSIONS: European national palliative care guidelines may not meet the needs of the growing population of people dying with cognitive impairment. New guidelines should consider suggesting the use of observational pain tools for people with cognitive impairment. Better recognition of their needs in palliative care guidelines may drive improvements in care.

Serial comprehensive geriatric assessment in elderly head and neck cancer patients undergoing curative radiotherapy identifies evolution of multidimensional health problems and is indicative of quality of life.

Head and neck (H&N) cancer is mainly a cancer of the elderly; however, the implementation of comprehensive geriatric assessment (CGA) to quantify functional age in these patients has not yet been studied. We evaluated the diagnostic performance of screening tools [Vulnerable Elders Survey-13 (VES-13), G8 and the Combined Screening Tool 'VES-13 + (17-G8)' or CST], the feasibility of serial CGA, and correlations with health-related quality of life evolution [HRQOL; European Organisation for Research and Treatment of Cancer Quality of Life Questionnaires (EORTC QLQ)-C30 and -HN35] during therapy in hundred patients, aged ≥65 years, with primary H&N cancer undergoing curative radio(chemo)therapy. Respectively 36.8%, 69.0%, 62.1% and 71.3% were defined vulnerable according to VES-13, G8, CST and CGA at week 0, mostly due to presence of severe grade co-morbidities, difficulties in community functioning and nutritional problems. At week 4, significantly more patients were identified vulnerable due to nutritional, functional and emotional deterioration. The CST did not achieve the predefined proportion necessary for validation. Vulnerable patients reported lower function and higher symptom HRQOL scores as compared with fit patients. A comparable deterioration in HRQOL was observed in both groups through therapy. In conclusion, G8 remains the screening tool of choice. Serial CGA identifies the evolution of multidimensional health problems and HRQOL conditions during therapy with potential to guide individualised supportive care.

The Belgian geriatric day hospitals as part of a care program for the geriatric patient: first results of the implementation at the national level.

PURPOSE: In order to deliver individual, specialized and multidisciplinary care for older people, the Belgian national health authorities developed the care program for the geriatric patient. In that context, 48 geriatric day hospitals (GDHs) have been financed by the government since January 1st 2006. The main objective of this study is to describe the patient characteristics, facility features and activities related to the Belgian GDHs. METHODS: A prospective, multicenter study was performed from October 1st till December 31st 2006 in all 48 GDHs. For each GDH a transversal data collection was carried out. In the same period all patients scheduled for the GDHs were registered and followed for 3 months. Therefore two questionnaires were developed using Filemaker software: one for each GDH and one for each patient. There were no exclusion criteria. RESULTS: Six GDHs did not complete one or both questionnaires. Consequently, the results of 42 GDHs were included. GDHs with more years of activity had significantly more new patient contacts per day. Activities in the Belgian GDHs were mainly diagnostic with emphasis on geriatric syndromes and specific medical problems. The reason for admission to the GDH was often multifactorial. The syndromes that motivated patients 75 or older to visit the GDH were clearly geriatric (mainly cognitive disorders) and represent the principle public health problems in this age category. Despite the legal provision preserving GDHs for patients 75 years or older a quarter of all patients was younger than 75, presenting with a geriatric syndrome. The contribution of the general practitioners was limited. CONCLUSIONS: Activities in the Belgian GDHs are mainly diagnostic with emphasis on geriatric syndromes (particularly cognitive disorders) and specific medical problems. More information is needed on the knowledge and expectations of general practitioners in order to establish a closer collaboration.

Do-not-resuscitate decisions in a large tertiary hospital: differences between wards and results of a hospital-wide intervention.

BACKGROUND: Despite the advent of palliative care, the quality of dying in the hospital remains poor. Differences in quality of end-of-life practice between hospital wards are well known in clinical practice but rarely have been investigated. METHODS: A prospective observation of do-not-resuscitate (DNR) decisions was conducted in patients dying in a Belgian university hospital before (115 patients) and after (113 patients) a hospital-wide intervention consisting in informing hospital staff on the law on Patient's Rights and the introduction of a new DNR form.The new DNR form puts more emphasis on the motivation of the DNR decision and on the description of the participants in the decision-making process. RESULTS: The completion of DNR forms improved after the intervention: physicians better documented who participated in DNR decisions (for participation of family: 63% after the intervention vs. 44% before the intervention, p = 0.022, for nurses: 27% vs. 14%, p = 0.047) and the motivation for these decisions (59% vs. 32%, p = 0.001). However, there was no difference in referral to the intensive care unit (ICU) at the end of life (in 40% of patients after and 37% before the intervention). Furthermore, the number of patients dying without DNR form on the wards was similar (13% and 8%). Surgical patients and patients with non-malignant diseases were more often referred to ICU at the end of life (71% in surgical vs. 35% in medical patients, p < 0.001 and 49% in patients with non-malignant diseases vs. 23% in patients with malignancy, p < 0.001). Moreover, surgical patients less frequently received a DNR order (56% in surgical vs. 92% in medical patients, p = 0.007). CONCLUSIONS: The introduction of a new DNR form and informing hospital staff on patients' right to information did not improve physicians' end-of-life practice.Transition from life-prolonging treatment to a more palliative approach was less anticipated in surgical patients and patients with non-malignant diseases.

Factors influencing ICU referral at the end of life in the elderly.

OBJECTIVE: Referral to the intensive care unit (ICU) and frequency of do-not-resuscitate (DNR) decisions at the end of life (EOL) in adult hospitalized patients≥75 years and those<75 years were examined and influencing factors in the elderly were determined. METHODS: Data were prospectively collected in all adult patients who deceased during a 12-week period in 2007 and a 16-week period in 2008 at a university hospital in Belgium. RESULTS: Overall, 330 adult patients died of whom 33% were ≥75 years old. Patients≥75 years old were less often referred to ICU at the EOL (42% vs. 58%, p=0.008) and less frequently died in the ICU (31% vs. 46%, p=0.012) as compared to patients<75 years old. However, there was no difference in frequency of DNR decisions (87% vs. 88%, p=0.937) for patients dying on non-ICU wards. After adjusting for age, gender, and the Charlson comorbidity index, being admitted on a geriatric ward (OR 0.30, 95% CI 0.10-0.85, p=0.024) and having an active malignant disease (OR 0.39, 95% CI 0.19-0.78, p=0.008) were the only factors associated with a lower risk of dying in the ICU. CONCLUSION: Patients≥75 years are less often referred to the ICU at the EOL as compared to patients<75 years old. However, the risk of dying in the ICU was only lower for elderly with cancer and for those admitted to the geriatric ward.

Palliative care for the geriatric patient in Europe. Survey describing the services, policies, legislation, and associations.

BACKGROUND: Knowledge about the quality of end-of-life care in the elderly patient in Europe is fragmented. The European Union Geriatric Medicine Society (EUGMS) Geriatric Palliative Medicine (GPM) Interest Group set as one of its goals to better characterize geriatric palliative care in Europe. OBJECTIVE: The goal of the current study was to map the existing palliative care structures for geriatric patients, the available policies, legislation, and associations in geriatric palliative medicine in different countries of Europe. METHODS: A questionnaire was sent to Geriatric and Palliative Medicine Societies of European countries through contact persons. The areas of interest were (1) availability of services for the management of geriatric patients by using vignette patients (advanced cancer, severe cardiac disease, and severe dementia), (2) policies, legislation of palliative care, and (3) associations involved in geriatric palliative medicine. RESULTS: Out of 21 countries contacted, 19 participated. Palliative care units and home care palliative consultation teams are available in most countries. In contrast, palliative care in long-term care facilities and in geriatric wards is less developed. A disparity was found between the available services and those most appropriate to take care of the three cases described in the vignettes, especially for the patient dying from non-malignant diseases. The survey also demonstrated that caregivers are not well prepared to care for the elderly palliative patient at home or in nursing homes. CONCLUSION: One of the challenges for the years to come will be to develop palliative care structures adapted to the needs of the elderly in Europe, but also to improve the education of health professionals in this field.

[Critical reflections concerning euthanasia for persons with dementia]. / Réflexions critiques à propos de l'euthanasie de personnes atteintes de démence.

In the public debate on the extension of euthanasia for people with dementia, in addition to ethical considerations and arguments, other issues have to be kept in mind. The diagnosis of dementia is difficult and the clinical picture is very fluctuating. The assessment and especially the operationalization of legal capacity and the use of advance directives are complex problems. The discussion should be conducted against the backdrop of a cultural framework in which the interpretation and development of palliative care is crucial. The development of a framework like advance care planning creates opportunities. The question remains whether the legal issues can be clarified and whether a legal approach generates solutions for the problems described.

Kidney in old age.

Epidemiological studies have shown that chronic kidney disease (CKD) is a major health problem especially in an older population. Given the growing segment of the elderly population and the important implication of renal disease on health care, this review discusses the structural and functional changes of the ageing kidney and the underlying mechanisms of age-dependent injury. The implications of these changes in daily clinical practice and the management of CKD is also briefly overviewed.

[Do-not-resuscitate policy on acute geriatric wards in Flanders, Belgium]. / Implementatie van niet-reanimeerbeleid op afdelingen acute geriatrie van Vlaamse ziekenhuizen in 2002 nog niet voltooid.

This study describes the historical development and status of a do-not-resuscitate (DNR) policy on acute geriatric wards in Flanders, Belgium. In 2002 (the year Belgium voted a law on euthanasia), a structured mail questionnaire was sent to all head geriatricians of acute geriatric wards in Flanders (N=94). Respondents were asked about the existence, development, and implementation of the DNR policy (guidelines and order forms). The response was 76.6%. Development of DNR policy began in 1985, with a step-up in 1997 and 200l. In 2002, a DNR policy was available in 86.1% of geriatric wards, predominantly with institutional DNR guidelines and individual, patient-specific DNR order forms. The policy was initiated and developed predominantly from an institutional perspective by the hospital. The forms were not standardized and generally lacked room to document patient involvement in the decision making process. Implementation of institutional DNR guidelines and individual DNR order forms on geriatric wards in Flanders lagged behind that of other countries and was still incomplete in 2002. DNR policies varied in content and scope and were predominantly an expression of institutional defensive attitudes rather than a tool to promote patient involvement in DNR and other end-of-life decisions.

A home-based multidimensional exercise program reduced physical impairment and fear of falling.

OBJECTIVE: To investigate the efficacy of a guided and graded home-based exercise program for improving a range of physical outcomes in older people. DESIGN: Controlled clinical trial of 16 weeks. SETTING: Two geographical areas in Gent, Belgium. PARTICIPANTS: 66 independent-living older people (age: 71-98) with a history of falls and moderate physical impairment. INTERVENTION: Twenty-four 30-minute training sessions were given by a trained physiotherapist over a period of 16 weeks in the participant's home. Different types of exercises on balance, aerobic performance, flexibility, and muscle strength were provided. MAIN OUTCOME MEASURES: Muscle strength, static and dynamic balance, aerobic performance, activities in daily living, fear of falling and avoidance of daily activities were assessed at baseline and after 16 weeks intervention. RESULTS: At baseline, there were no significant differences in the measured variables between exercise and control groups. After 16 weeks, the exercise group showed significantly improved ankle muscle strength, balance performance and aerobic capacity, and decreased fear of falling, dependency in daily activities and avoidance of daily activities compared to the control group. The improvements in knee muscle strength, timed chair stands, and functional reach were not significant. CONCLUSION: The home-based, individualized exercise program was effective in reducing several physical factors associated with falls in community-dwelling older people with moderate physical impairment. The decrease in fear of falling and other behavioural variables needs to be considered with care and needs further investigation.