[Avoidable visual impairment among residents in care institutions: lessons from an intervention project in the Den Bosch region]. / Onnodige slechtziendheid onder ouderen in zorginstellingen: lessen uit een interventieproject in de regio Den Bosch.

INTRODUCTION: Many elderly in care institutions in The Netherlands are visually impaired (visual acuity < 0.3). They fall more frequently, are more depressed and require more care. In this project visually impaired residents were identified and referred for adequate eye care. The aim of this study is to evaluate the intervention, including validation of the screening, assessment of the prevalence and causes of visual impairment as well as the outcome of the treatment. The effectiveness of the care chain is also evaluated. MATERIALS AND METHODS: 640 residents were offered a basic eye examination and 210 of them were referred, via their general practitioner, to an optometrist (10), ophthalmologist (98), or centre for visually impaired persons (1). RESULTS: Compliance in this study was poor. The prevalence of visual impairment (24%) was lower than in comparable studies. Cataract was the main cause in 51%. Overall 17 (8.1%) residents were treated by ophthalmologists and nine (4.3%) were referred to optical shops. Constraints in the care chain are identified. DISCUSSION: Vision screening in care institutions for elderly is feasible and useful. The care chain should be shorter and simpler. That will increase the effectiveness of this intervention, and thereby the quality of life for many residents.

Patient satisfaction after corneal transplantation.

PURPOSE: To determine the relationship between objective and subjective outcome measures and patient satisfaction after corneal transplantation. METHODS: Data were collected for 184 patients who underwent a corneal transplantation between 1 and 5 years ago. Only patients with the diagnosis of bullous keratopathy, endothelial decompensation (or Fuchs dystrophy), nonherpetic keratitis, and keratoconus were included. Objective treatment outcome measures, such as clarity of the graft and visual acuity in the grafted eye, were collected prospectively. Visual acuity of the other eye was collected retrospectively by chart review. Subjective outcome measures were derived from a retrospective survey. In addition to assessment of patient satisfaction, the survey provided information regarding subjective outcome measures, such as visual functioning and quality of life. RESULTS: The response rate was 86%. Generally, patients indicated that they were satisfied with the results of the transplantation. Age was negatively related to satisfaction, with older patients being less satisfied. On average, patients with keratoconus were most satisfied. Subjective outcome measures explained 57% of the variance in patient satisfaction, whereas objective factors explained 12%. Receipt of patient education during treatment was the best predictor. Other important variables were quality of life and visual functioning. CONCLUSION: In general, corneal transplantation had a positive effect on objective and subjective outcome measures. Patient satisfaction was better predicted by subjective outcomes than by objective outcomes. Patient education, in particular, proved to be a crucial factor. Objective outcome measures appeared to have a more indirect influence on patient satisfaction.

Determinants of doctor consultation for micturition problems in an elderly male population.

OBJECTIVE: To study which factors influence doctor consultation when a subject has micturition problems. METHODS: Postal questionnaire in an open population of older men (n = 1,695), followed by investigations in 10 general practices, including uroflowmetry. RESULTS: 25% of the men had micturition problems, of which 10-30% presented their symptoms to a doctor. Almost 60% experienced an influence of their micturition habits on activities of daily living. More than 85% of the men were not able to compare their micturition pattern with others. In multiple logistic regression, presentation to a doctor was independently associated with obstructive symptoms, dysuria, men defining their situation as a complaint, depressive mood, more frequent sexual desire and smoking. Many other factors which might play a role in diagnosis and timing of treatment were not found to influence consultation. CONCLUSION: Most men deal with micturition problems without consulting, although symptoms have a substantial impact on daily life. Consultation was associated with symptoms, psychological factors and smoking.

[Home visits by community health nurses can contribute to the family practitioner's knowledge of elderly patients]. / Huisbezoek door de wijkverpleegkundige kan bijdragen aan de kennis van de huisarts over oudere patiënten.

OBJECTIVE: To determine to what extent the general practitioner (GP) is aware of the health status and functioning of his elderly patients and in which areas this knowledge can be completed with the aid of community nurses. DESIGN: Cross-sectional, descriptive. SETTING: Department of General Practice. State University Limburg, Maastricht, the Netherlands. METHODS: A random sample of 59 patients aged 79 years and over, belonging to the population of a primary health care centre, were visited by community nurses. One patient was lost. The nurses inventoried the patients health complaints and their daily functioning by means of a structured questionnaire. Data from these home visits were compared with data from the same questionnaire, regarding the same patients, which the three GPs of the health centre had filled in on the basis of their medical records. RESULTS: Of the complaints recorded by the community nurses. 34% were not known to the general practitioners. This concerned mainly symptoms of depression, urinary incontinence, disabilities and handicaps of the musculoskeletal system. sleep disturbances, daily functioning and ability to cope. The main determinants of the ability to cope were impaired walking and to a lesser degree symptoms of depression. CONCLUSION: A structured interview of elderly patients by a community nurse yields substantial information about health problems.

Anticipatory care and the role of Dutch general practice in health promotion--a critical reflection.

The Dutch GP is in a unique (potential) position within the health care system with regard to clinical health promotion. An essential feature is the integration in the regular consultation. The concept of anticipatory care seems fit to understand this integration. Because of the GP's (anticipatory) knowledge of the patient's medical history, lifestyle, risk factors, living conditions, health perceptions and family context, he has the opportunity to include during the consultation, aspects of health promotion and disease prevention. The production of evidence-based guidelines by the Dutch College of General Practitioners greatly enhances the integration of health promotion within the consultation. Strategies for the implementation are needed on three different levels: encouragement of the patient to ask questions, training of the GP and organization of the practice. An important aspect of the last strategy concerns systematic delegation of health promotion tasks, usually related to the guidelines, to the practice assistant or practice nurse. Recent legislation in the Netherlands underlines and advances the above mentioned trends.

A troubled youth: relations with somatization, depression and anxiety in adulthood.

BACKGROUND: Childhood experiences profoundly affect later functioning as an adult. Family practitioners are well-placed to discover the links between childhood troubles and later somatization, depression or anxiety. OBJECTIVES: We aimed to study the interrelation of somatization, depressive and anxiety disorders in frequently attending patients in general practice; to investigate whether these problems are related to a childhood history of illness experiences, deprivation, life events and abuse; and to determine the independent contributions of these childhood factors to the prediction of adult somatization, depressive and anxiety disorders. METHODS: One hundred and six adult general practice patients with high consultation frequency were studied. Somatization was operationalized as a more comprehensive version of DSM-III-R somatization disorder (5 complaints; SSI 5/5). For depression (ever depressive and/or dysthymic) and anxiety (panic, phobias and/or generalized anxiety) DSM-III-R criteria were used. Using a structured questionnaire we assessed illness experiences, deprivation of parental care, abuse (sexual/physical) and other life events before age 19. RESULTS: The overlap between somatization, depression and anxiety was largely accounted for by 16 patients with a triple problem: somatization and depression and anxiety. Somatization was specifically related to deprivation, depression to other life events. Abuse (prevalence 16%) independently predicted psychiatric problems in general. Youth experiences before age 12 were most important. CONCLUSIONS: The high prevalence of triple problems suggests a need to reconsider concepts like somatic anxiety and anxious depression. The specificity of the relation between deprivation and somatization and of the relation between other life events and depression indicates that distinct causal mechanisms (in youth) contribute to these problems.

Somatization in frequent attenders of general practice.

The DSM-III-(R) definition of somatization disorder is too restrictive for use in general practice. A more comprehensive definition, the "somatic symptom index" (SSI) has shown good validity in open populations. However, a definition has to differentiate validly within a population of frequent attenders to be a useful diagnostic instrument in general practice. We studied a threshold of five complaints (nearly identical to the SSI) in 80 Dutch general practice patients. Patients were selected on age (20-44 years), history of back, neck or abdominal complaints, and on frequency of consultation- at least 12 consultations in the previous 3 years, corrected for consultations with compelling somatic reason for encounter. Prevalence of somatization in this group was 45%. Women had a 2 times higher risk of somatization. A relation with age was not found. Somatization was related to depressive complaints (relative risk 2.5) and probably also to anxiety. Somatizing patients consulted their general practitioner more often and had more health problems (especially psychic problems) than non-somatizers. These results support the validity of this definition. The distinction between our definition of somatization and somatization defined as a symptom of psychiatric (e.g. depressive or anxiety) disorder is emphasized.

Membership of a patients' association and well-being. A study into the relationship between membership of a patients' association, fellow-patient contact, information received, and psychosocial well-being of people with a neuromuscular disease.

This article presents the results of a study into the relationship between membership of a patients' association, information received, fellow-patient contact and psychosocial well-being. Data were collected from a group of people with myotonic dystrophy and spinal muscular atrophy (n = 349). About 60% of this group are members of a patients' association for people with a neuromuscular disease. No direct relationship was found between membership of the patients' association and well-being. Membership, however, was positively related to the number of fellow-patients with whom one has had personal contact and also to the amount of information received about the disease and related factors. Having personal contact with more fellow-patients was related to a better well-being in the group of patients who had a relatively low level of physical functioning. There were no indications that receiving information leads to better well-being. The results of this study indicate that membership of a patients' association, through promoting fellow-patients contacts, can be beneficial to people with a chronic disease, especially to people who are relatively severely ill.