[Geriatric rehabilitation care: Doing the right things right]. / Geriatrische Revalidatiezorg: De juiste dingen goed doen.

BACKGROUND: Geriatric rehabilitation concerns short-term integrated multidisciplinary care aimed at functional recovery and social participation for relatively frail elderly. Given the geriatric clients' complex care issues, nurses should possess sufficient and appropriate competencies in order to identify and assess the relevant symptoms and intervene effectively. Yet, nurses experience a certain apprehensiveness to perform their tasks and express difficulties in multidisciplinary communication and collaboration in a constructive manner. In addition to the client's and informal care giver's perception of their input in the geriatric rehabilitation process, this study provides an in-depth understanding of the way nurses perceive their role in geriatric rehabilitation. METHODS/DESIGN: This descriptive study entails a quantitative and a qualitative component. The quantitative component concerns questionnaires for clients, informal care givers, nurses, and team leaders. The qualitative component aims to obtain in-depth information (i. e. opinions, meanings, and reflections) with regard to the decision making process and the performance of the rehabilitation care by means of open-ended questions (in the questionnaire) and semi-structured interviews. RESULTS: Clients and informal care givers rate specific themes in geriatric rehabilitation in a more negative light than nurses and team leaders do. These themes concern the provision of information in the hospital (prior to admission in the rehabilitation facility), involvement in the draw-up of the treatment plan and rehabilitation goals, geriatric rehabilitation as a 24/7 activity, and taking into account the client's other life events. The latter three findings in particular, are caused by nurses' apprehensiveness to perform their tasks adequately. DISCUSSION: Nurses working in geriatric rehabilitation, experience apprehensiveness to perform their tasks adequately. Uncertainty about the client's reaction or fear of damaging the relationship of trust, results in nurses not involving the clients and informal care givers in the draw-up of the rehabilitation goals. Apprehensiveness also submerges as the lack of experience or specific competences in considering the client's other life events. The recommendations address these aspects in particular.

Er is disciplinebreed sprake van relatieve onbevoegdheid en onbekwaamheid op het gebied van kwetsbare ouderen.

There is much negative publicity about the health care for the frail elderly especially in nursing homes. However, in scientific research programs the results are also quite disappointing. We see a low percentage (< 50 %) of treatment fidelity in the intervention programs at stake. Research on the education content with respect to the frail elderly showed that this is very poor for every profession. From the perspective of formal education the professionals who provide treatment and care the frail elderly are relatively unqualified and incompetent. Government, health inspection and umbrella organizations should focus on solving this issue instead of enforcing their control mechanisms. Formal education is the hallmark of quality treatment and care especially in case of complex and unpredictable health problems of the frail elderly. If we don't change our policy and don't invest in the solution of fundamental educational shortcomings we continue to build on quicksand.To formulate and subscribe a smart covenant by the key players to solve this issue within five years is imperative.

[INTEGRATED APPROACH TO PREVENT FUNCTIONAL DECLINE IN HOSPITALIZED ELDERLY]. / Integrale interventie ter voorkoming van functieverlies bij ouderen tijdens ziekenhuisopname: het Zorgprogramma voor Preventie en Herstel.

BACKGROUND: Hospital related functional decline in older patients is an underestimated problem. Thirty-five procent of 70-year old patients experience functional decline during hospital admission in comparison with pre-illness baseline. This percentage increases considerably with age. METHODS/DESIGN: To address this issue, the Vlietland Ziekenhuis in The Netherlands has implemented the Prevention and Reactivation Care Programme (PReCaP), an innovative program aimed at reducing hospital related functional decline among elderly patients by offering interventions that are multidisciplinary, integrated and goal-oriented at the physical, social, and psychological domains of functional decline. DISCUSSION: This paper presents a detailed description of the intervention, which incorporates five distinctive elements: (1) Early identification of elderly patients with a high risk of functional decline, and if necessary followed by the start of the reactivation treatment within 48 h after hospital admission; (2) Intensive follow-up treatment for a selected patient group at the prevention and Reactivation Centre; (3) Availability of multidisciplinary geriatric expertise; (4) Provision of support and consultation of relevant professionals to informal caregivers; (5) Intensive follow-up throughout the entire chain of care by a casemanager with geriatric expertise. Outcome and process evaluations are ongoing and results will be published in a series of forthcoming papers. This article is an edited translation of the previously published article 'Integrated approach to prevent functional decline in hospitalized elderly: the Prevention and Reactivation Care Program (PReCaP), BMC Geriatrics 2012;12:7, AJBM de Vos, KJE Asmus-Szepesi, TJEM Bakker, PL de Vreede, JDH van Wijngaarden, EW Steyerberg, JP Mackenbach, AP Nieboer.

The importance of multidisciplinary teamwork and team climate for relational coordination among teams delivering care to older patients.

AIM: To identify predictors of relational coordination among professionals delivering care to older patients. BACKGROUND: Relational coordination is known to enhance quality of care in hospitals. The underlying mechanisms, however, remain poorly understood. DESIGN: This cross-sectional study was part of a larger evaluation study examining the opportunity to prevent loss of function in older patients due to hospitalization in the Netherlands. METHODS: This study was performed in spring 2010 among team members delivering care to older hospitalized patients (192 respondents; 44% response rate) in one hospital. Relational coordination was measured by the Relational Coordination survey; team climate by the Team Climate Inventory and questions were asked about participation in multidisciplinary team meetings and disciplines represented in these meetings. To account for the hierarchical structure, a multilevel analysis was performed. RESULTS: Correlation analysis revealed a positive relationship among being female, being a nurse and relational coordination; medical specialists showed a negative relationship. The number of disciplines represented during multidisciplinary team meetings and team climate were positively related with relational coordination. The multilevel analysis showed a positive relationship between the number of disciplines represented during multidisciplinary team meetings and team climate with relational coordination. CONCLUSIONS: The enhancement of team climate and attendance of diverse professionals during multidisciplinary team meetings are expected to improve relational coordination. Furthermore, this study underscores the importance of enhancing relational coordination between medical specialists and other professionals.

Understanding older patients' self-management abilities: functional loss, self-management, and well-being.

PURPOSE: This study aimed to increase our understanding of self-management abilities and identify better self-managers among older individuals. METHODS: Our cross-sectional research was based on a pilot study of older people who had recently been admitted to a hospital. In the pilot study, all patients (>65 years of age) who were admitted to the Vlietland hospital between June and October 2010 were asked to participate, which led to the inclusion of 456 older patients at baseline. A total of 296 patients (65% response rate) were interviewed in their homes 3 months after admission. Measures included social, cognitive, and physical functioning, self-management abilities, and well-being. We used descriptive, correlations, and multiple regression analyses. In addition, we evaluated the mediation effect of self-management abilities on well-being. RESULTS: Social, cognitive, and physical functioning significantly correlated with self-management abilities and well-being (all p ≤ 0.001). After controlling for background characteristics, multiple regression analysis indicated that social, cognitive, and physical functioning still related to self-management abilities (ß = 0.17-0.25; all p ≤ 0.001). Older people with low levels of social, cognitive, and physical functioning were worse self-managers than were those with higher levels of functioning. CONCLUSIONS: Self-management abilities mediate the relationship between social, cognitive, and physical functioning and well-being. Interventions to improve self-management abilities may help older people better deal with function losses as they age further.

The relationship between older adults' self-management abilities, well-being and depression.

This study aimed to identify the relationship between self-management abilities, well-being and depression. Our study was conducted among older adults (>65 years of age) who were vulnerable to loss of function after hospital discharge. Three months after hospital admission, 296/456 patients (65 % response rate) were interviewed in their homes. The 30-item Self-Management Ability Scale was used to measure six self-management abilities: taking initiative, investing in resources for long-term benefits, taking care of a variety of resources, taking care of resource multifunctionality, being self-efficacious and having a positive frame of mind. Well-being was measured with the Social Production Function (SPF) Instrument for the Level of Well-being (SPF-IL) and Cantril's ladder. The Geriatric Depression Scale was used to assess depression. Correlation analyses showed that all self-management abilities were strong indicators for well-being (p < 0.001 for all). Regression analyses revealed that investing in resources for long-term benefits, taking care of a variety of resources, taking care of resource multifunctionality and being self-efficacious were associated with well-being. While no significant relationship was found between well-being and having a positive frame of mind or taking initiative, regression analyses revealed that these self-management abilities were related to depression. Investing in resources for long-term benefits and taking care of a variety of resources were significantly related to depression. This research showed that self-management abilities are related to well-being and depression among older adults. In addition, this study identified key self-management abilities for older adults who had recently been discharged from a hospital.

[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.

[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.

Prevalence of psychiatric function disorders in psychogeriatric patients at referral to nursing home care--the relation to cognition, activities of daily living and general details.

OBJECTIVES: This prospective, observation study (from June 2001 to October 2002) estimated the prevalence and co-occurrence of psychiatric function disorders (PFDs) in psychogeriatric patients suffering from cognitive function disorders at referral to clinical as well as non-clinical (transmural) psychogeriatric programmes. It is expected that PFDs, both total and individual, are positively related to the cognitive function disorders as well as the activities of daily living (ADL) handicaps. This expectation will be adjusted for general details particularly gender, age, marital status, domicile and type of primary caregiver. Exploratively, the structure of the interrelationship of PFDs, cognitive function disorders and ADL handicaps will be analysed. In addition, the general details and the structure to be identified will be described. METHODS: We studied patients aged > or = 65 years (n = 487), who were suspected to suffer from cognitive function disorders (MMSE < or = 29) and were referred to trans-/intramural nursing home care in the Nieuwe Waterweg Noord region. General details, i.e. gender, age, marital status, domicile, primary caregiver, as well as PFDs (the Neuropsychiatric Inventory, NPI), cognition (MMSE) and ADL (Barthel Index, BI) were assessed. RESULTS: Mean score NPI was 3.6 (SD = 2.3). Of the patients, 91.7% scored one or more NPI symptom; 81.6% two or more. Depression (43.9%), apathy (43.1%), anxiety (41.6%) and agitation/aggression (31.2%) had a high prevalence. With respect to the NPI symptoms, i.e. delusion, hallucination, anxiety (more in women), agitation/aggression and irritability (more in men), there were significant gender differences on the same MMSE level. Compared with women, men were significantly younger, ADL independent, lived together with their spouse, who was often the primary caregiver. The performance of the logistic regression models for total NPI score with MMSE, BI separately as well as combined with general details was minor. The results of the regression analyses for the individual NPI symptoms showed comparable low R(2) values; they explained a small proportion of the variance. However, in the PRINCALS analysis the MMSE and BI highly correlated with the cognitive dimension, and the NPI with the psychiatric dimension. The model fit was good; 82.6% of the variance was explained. CONCLUSION: At the moment of referral to nursing home care, the prevalence and co-occurrence of PFDs was high. The four main NPI symptoms were depression, apathy, anxiety and agitation/aggression. On the same level of MMSE score, gender difference was important for 3 NPI symptoms: delusion, hallucination and anxiety. NPI scores (total and per symptom) were relatively independent from MMSE, BI and general details. The PFDs--measured by the NPI--were a dimension on their own. Therefore, in psychogeriatrics it is of clinical relevance to think and act in terms of dimensions. Irrespective of a more rational psychopharmaceutical regime, this opens the door to the regular psychiatric domain for (psycho)therapeutic strategies, e.g. for depression and anxiety adapted to the kind and level of the cognitive function disorder of the psychogeriatric patient.

Life expectancy following psychogeriatric reactivation. Identification of prognostic characteristics of survival assessed on admission.

OBJECTIVES: To estimate life expectancy of psychogeriatric patients having participated in a reactivation program. To identify prognostic characteristics - on admission - for survival after discharge. DESIGN: A prospective, clinical-empirical observational study. SETTING: A Dutch psychiatric-skilled nursing home. PARTICIPANTS: Psychogeriatric patients (n = 75) suffering from very mild to moderate cognitive function disorders in conjunction with psychiatric function disorders. INTERVENTION: Interdisciplinary reactivation program. MEASUREMENTS: General, functional and diagnostic patient characteristics assessed on admission for the psychogeriatric reactivation program, and survival rate after discharge over a period of 7 years. RESULTS: The probability of survival for patients who were discharged from the psychogeriatric reactivation program to their own homes or to a residential home with restricted support ('independent' group, n = 53) was higher (1/HR = 3.2) than for patients who were discharged to a nursing home ('dependent' group, n = 22). The median survival period of the reference group (community-dwelling elderly people) was 95 months (95% confidence interval, CI: 74-116), that of the 'independent' group 35 months (95% CI: 25-45) and that of the 'dependent' group 13 months (95% CI: 3-22). For the reactivated patients (n = 75), gender was the only general characteristic of prognostic value for survival after discharge (the survival rate for women was higher; hazard ratio (HR) = 3.07; 95% CI: 1.61-5.85). Age was statistically insignificant. One functional characteristic, the Global Deterioration Scale, was of prognostic significance (HR = 1.58; 95% CI: 1.11-2.23). The diagnostic characteristics of prognostic significance were: psychiatric function disorders (paranoia; HR = 2.19; 95% CI: 1.11-4.28), somatic comorbidity (urogenital pathology; HR = 1.83; 95% CI: 1.13-2.94; cardiopulmonary pathology; HR = 1.56; 95% CI: 1.16-2.07) and adequacy of the caregiver system (HR = 0.59; 95% CI: 0.33-1.03). The specific diagnostic classifications of cognitive function disorders (DSM-IV) were not of prognostic significance. It was possible to account for 32% of the variance in survival after discharge. CONCLUSION: The survival rate of the 'independent' group of patients was obviously higher (1/HR = 3.2) than that of the 'dependent' group. There was no overlap in the 95% CI of the median survival period after discharge. The results suggest that with respect to survival the two groups of psychogeriatric patients who participated in the intensive reactivation program differed definitely. Additionally, patients belonging to the 'independent' group had a greater chance to benefit from a reactivation program. The program should pay special attention to the patient characteristics on admission, which demonstrated a significant negative correlation to survival. These patient characteristics belonged to five domains (i.e. gender, cognitive function disorders, psychiatric function disorders, somatic comorbidity and adequacy of the caregiver system) The five dimensions are of clinical interest for optimizing the selection of patients who may derive most benefit from a reactivation program. The development of a valid prognostic instrument is a prerequisite for optimal medical decision-making for such intensive intervention programs, as is the analysis of cost-effectiveness. In order to draw firm conclusions, it is recommended that a large-scale study with a randomized, parallel-group design will be performed. Our group has started such a research program in July 2001.

[Rational-emotive therapy in psychogeriatrics: a new application? Case report of a patient in daycare]. / Rationeel--emotieve therapie in de psychogeriatrie: een nieuwe toepassing? Casusbeschrijving van een dagbehandelinspatiënt.

Literature indicates that the use of psychotherapeutic techniques in affective problems in patients with cognitive impairment is scarce and often considered to be ineffective. The feasibility of an individual treatment with Rational Emotive Therapy of a psychogeriatric patient was explored. The patient was diagnosed with moderate cognitive impairment, a depressive episode and generalised anxiety disorder. Simplification of the RET principles and integration in an interdisciplinary system were introduced as adjustments in the method. The treatment resulted in a reduction of depressive and anxiety complaints. Treatment limitations and patient variables which seemed to have contributed to the treatment success and which may have predictive value are discussed.

Psychogeriatric reactivation in a psychiatric-skilled nursing home: a clinical-empirical exploration.

OBJECTIVE: To identify prognostic characteristics for the probability of discharge of psychogeriatric patients with functional-psychiatric pathology, in order to optimize patient selection for the reactivation programme. METHODS AND MATERIALS: A retrospective, clinical, empirical study in a Dutch psychiatric nursing home. A group of 102 patients, consecutively enrolled in a psychogeriatric reactivation programme and who met the inclusion and exclusion criteria, was retrospectively examined. The general, functional and diagnostic characteristics were assessed at baseline. RESULTS: The general characteristics of the reactivation-programme patients were not of prognostic value. However, functional characteristics (GDS, HI and ADL score) were prognostically important. In addition, diagnostic characteristics were identified within the following four domains: cognitive function disorder, functional-psychiatric pathology, an inadequate caregiver system at home, and somatic comorbidity. The prognostic value of the specific diagnostic classification of cognitive function disorders (with the exception of delirium) was irrelevant. CONCLUSION: Reactivation seems a promising programme for frail, elderly psychogeriatric patients with functional-psychiatric pathology, but without substantial deterioration of cognitive function disorders and self-care deficits. It proved possible to make advance estimates of the probability of discharge for such patients, which is of clinical interest. Before a reliable and valid prognostic instrument can be constructed, the patients' functional and diagnostic characteristics should be prospectively assessed. Ideally, a study with a randomized, controlled, parallel group design would be used for this purpose.

Palliative care in chronic psycho-geriatrics: a case-study.

In this case-study the relevance of psycho-social interventions for providing palliative care in the terminal phase of life of psycho-geriatric patients with functional-psychiatric co-pathology is described. The know-how, interventions and facilities such as available in a reactivation unit in a 'psychiatric-skilled' Dutch nursing home, were highly relevant to tune palliative care to the needs and abilities of the patient. The application of the four main-dimensions of the method of Dynamic System Analysis (particularly Cognitive functions, Psychological functions, Social context and Biology) can stimulate professionals to use an integral perspective both to the psycho-social needs of terminal psycho-geriatric patients and their relatives and to the biological aspects. To establish the value of the DSA method for providing palliative care to psycho-geriatric patients with functional-psychiatric co-pathology scientific research is recommended to determine the prognostic profile of patients who benefit most from an actual palliative care program.