Implementing a Personalized Integrated Stepped-Care Method (STIP-Method) to Prevent and Treat Neuropsychiatric Symptoms in Persons With Dementia in Nursing Homes: Protocol for a Mixed Methods Study.

BACKGROUND: Neuropsychiatric symptoms occur frequently in many nursing home residents with dementia. Despite the availability of multidisciplinary guidelines, neuropsychiatric symptoms are often inadequately managed. Three proven effective methods for managing neuropsychiatric symptoms were integrated into a single intervention method: the STIP-Method, a personalized integrated stepped-care method to prevent and treat neuropsychiatric symptoms. The STIP-Method comprises 5 phases of clinical reasoning to neuropsychiatric symptoms and 4 stepped-care interventions and is supported with a web application. OBJECTIVE: This study aims to identify the facilitators and barriers in the implementation of the STIP-Method in nursing homes. METHODS: A mixed methods design within a participatory action research was used to implement the STIP-Method in 4 facilities of 2 Dutch nursing home organizations. In total, we aimed at participation of 160-200 persons with dementia and expected an intervention fidelity of 50% or more, based on earlier studies regarding implementation of effective psychosocial interventions to manage neuropsychiatric symptoms. All involved managers and professionals were trained in the principles of the STIP-Method and in using the web application. An advisory board of professionals, managers, and informal caregivers in each facility supported the implementation during 21 months, including an intermission of 6 months due to the COVID-19 pandemic. In these 6-weekly advisory board meetings, 2 researchers stimulated the members to reflect on progress of the implementation by making use of available data from patient records and the web application. Additionally, the 2 researchers invited the members to suggest how to improve the implementation. Data analysis will involve (1) analysis of facilitators and barriers to the implementation derived from verbatim text reports of advisory board meetings to better understand the implementation process; (2) analysis of patient records in accordance with multidisciplinary guidelines to neuropsychiatric symptoms: personalized, interdisciplinary, and proactive management of neuropsychiatric symptoms; (3) evaluation of the web application in terms of usability scores; (4) pre- and postimplementation analysis of patient records and the web application to evaluate the impact of the STIP-Method, such as changes in neuropsychiatric symptoms and informal caregiver burden. RESULTS: We enrolled 328 persons with dementia. Data collection started in July 2019 and ended in December 2021. The first version of this manuscript was submitted in October 2021. The first results of data analysis are expected to be published in December 2022 and final results in June 2023. CONCLUSIONS: Our study may increase understanding of facilitators and barriers to the prevention and treatment of neuropsychiatric symptoms in nursing home residents with dementia by implementing the integrated STIP-Method. The need for well-designed implementation studies is of importance to provide nursing homes with optimal tools to prevent and treat neuropsychiatric symptoms. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/34550.

e-Learning and Web-Based Tools for Psychosocial Interventions Addressing Neuropsychiatric Symptoms of Dementia During the COVID-19 Pandemic in Tokyo, Japan: Quasi-Experimental Study.

BACKGROUND: Concern has been raised that the COVID-19 pandemic and consequent social distancing measures may increase neuropsychiatric symptoms in people with dementia. Thus, we developed and delivered an e-learning training course to professional caregivers on using a web-based tool for psychosocial interventions for people with dementia. OBJECTIVE: The aim of our study was to evaluate the feasibility and efficacy of an e-learning course in combination with a web-based tool in addressing neuropsychiatric symptoms of dementia. METHODS: A quasi-experimental design was used in Tokyo, Japan. The e-learning course was delivered three times to professional caregivers between July and December 2020. Caregivers who completed the course assessed the level of neuropsychiatric symptoms in people with dementia using the total score from the Neuropsychiatric Inventory (NPI) via a web-based tool. The primary outcome measures were the number of caregivers who implemented follow-up NPI evaluations by March 2021 and the change in NPI scores from baseline to their most recent follow-up evaluations. As a control group, information was also obtained from professional caregivers who completed a face-to-face training course using the same web-based tool between July 2019 and March 2020. RESULTS: A total of 268 caregivers completed the e-learning course in 2020. Of the 268 caregivers, 56 (20.9%) underwent follow-up evaluations with 63 persons with dementia. The average NPI score was significantly reduced from baseline (mean 20.4, SD 16.2) to the most recent follow-up evaluations (mean 14.3, SD 13.4). The effect size was assumed to be medium (Cohen drm [repeated measures]=0.40). The control group consisted of 252 caregivers who completed a face-to-face training course. Of the 252 caregivers, 114 (45.2%) underwent follow-up evaluations. Compared to the control group, caregivers who completed the e-learning course were significantly less likely to implement follow-up evaluations (χ21=52.0, P<.001). The change in NPI scores did not differ according to the type of training course (baseline-adjusted difference=-0.61, P=.69). CONCLUSIONS: The replacement of face-to-face training with e-learning may have provided professionals with an opportunity to participate in the dementia behavior analysis and support enhancement (DEMBASE) program who may not have participated in the program otherwise. Although the program showed equal efficacy in terms of the two training courses, the feasibility was suboptimal with lower implementation levels for those receiving e-learning training. Thus, further strategies should be developed to improve feasibility by providing motivational triggers for implementation and technical support for care professionals. Using online communities in the program should also be investigated.

[Recognizing the role of personality disorders in problem behavior of elderly residents in nursing home and homecare.] / (H)erken de rol van de persoonlijkheid bij probleemgedrag van cliënten in het verpleeghuis en in de thuiszorg.

Problem behavior is frequently present in older people living in nursing homes or needing home care services. When Personality disorders or maladaptive traits are involved these older people need specific care. In addition, they and their carers might experience psychological suffering as their behavior is not always properly recognized as the result of their personality. The importance of multidisciplinary teamwork, the role of psychiatric consultation given by an elderly psychiatrist as well as the need for upgrading the knowhow within the care sector itself is discussed using 2 vignettes.

Recovery from burden: informal caregiver profiles that predict treatment success.

ABSTRACTBackground:Neuropsychiatric symptoms (NPI) of dementia are important determinants of caregiver burden, while caregiver coping styles and competences can relieve burden. Caregivers differ in coping with the demands made on them and in experienced burden. What changes in caregivers explain recovery from burden, and which caregiver characteristics predict recovery from burden over time, and does treatment make a difference? METHODS: This study into recovery from burden was a secondary analysis of data collected in a formerly conducted randomized controlled trial (RCT) on the integrated reactivation and rehabilitation (IRR) programme in a psychiatric-skilled nursing home, compared to usual care (UC; i.e. day care, assisted living arrangements, and nursing home wards). For this secondary analysis, longitudinal data on persons with dementia and caregivers were used from baseline (T1), end of treatment (T2), and at nine months (T3). RESULTS: Caregivers with an improved sense of competence (SCS) who care for persons with dementia with a decreased severity of NPI have the highest chance of recovering from burden (CSI). Caregivers with a tendency to feel involved with others and sympathize with others (affiliation, ICL-R) have a slightly lower probability of improvement with respect to their sense of competence in the short term. The number of improved caregivers was higher in IRR than UC. CONCLUSION: Recovery depends on both an improved sense of competence and a decreased severity of NPI. Combined interventions that address both NPI and focus on enhancing caregiver's sense of competence have added value when it comes to decreasing caregiver burden.

Is socially integrated community day care for people with dementia associated with higher user satisfaction and a higher job satisfaction of staff compared to nursing home-based day care?

OBJECTIVES: To investigate whether community-based (CO) day care with carer support according to the proven effective Meeting Centres Support Programme model is associated with higher satisfaction of people with dementia (PwD) and their informal caregivers (CG) and with a higher job satisfaction among care staff compared to traditional nursing home-based (NH) day care. METHOD: Data were collected in 11 NH day care centres and 11 CO day care centres. User satisfaction of PwD and CG was evaluated in the 11 NH day care centres (nPwD = 41, nCG = 39) and 11 CO day care centres (nPwD = 28, nCG = 36) with a survey after six months of participation. Job satisfaction was measured only in the six NH day care centres that recently transformed to CO day care, with two standard questionnaires before (nSTAFF = 35), and six months after the transition (nSTAFF = 35). RESULTS: PwD were more positive about the communication and listening skills of staff and the atmosphere and activities at the CO day care centre. Also, CG valued the communication with, and expertise of, staff in CO day care higher, and were more satisfied with the received emotional, social and practical support. After the transition, satisfaction of staff with the work pace increased, but satisfaction with learning opportunities decreased. CONCLUSION: PwD and CG were more satisfied about the communication with the staff and the received support in CO day care than in NH day care. Overall job satisfaction was not higher, except satisfaction about work pace.

Understanding implementation of comprehensive geriatric care programs: a multiple perspective approach is preferred.

BACKGROUND: The Prevention and Reactivation Care Program (PReCaP) provides a novel approach targeting hospital-related functional decline among elderly patients. Despite the high expectations, the PReCaP was not effective in preventing functional decline (ADL and iADL) among older patients. Although elderly PReCaP patients demonstrated slightly better cognitive functioning (Mini Mental State Examination; 0.4 [95% confidence interval (CI) 0.2-0.6]), lower depression (Geriatric Depression Scale 15; -0.9 [95% -1.1 to -0.6]), and higher perceived health (Short-form 20; 5.6 [95% CI 2.8-8.4]) 1 year after admission than control patients, the clinical relevance was limited. Therefore, this study aims to identify factors impacting on the effectiveness of the implementation of the PReCaPand geriatric care 'as usual'. METHODS: We conducted semi-structured interviews with 34 professionals working with elderly patients in three hospitals, selected for their comparable patient case mix and different levels of geriatric care. Five non-participatory observations were undertaken during multidisciplinary meetings. Patient files (n = 42), hospital protocols, and care plans were screened for elements of geriatric care. Clinical process data were analysed for PReCaP components. RESULTS: The establishment of a geriatric unit and employment of geriatricians demonstrates commitment to geriatric care in hospital A. Although admission processes are comparable, early identification of frail elderly patients only takes place in hosptial A. Furthermore, nursing care in the hospital A geriatric unit excels with regard to maximizing patient independency, an important predictor for hospital-related functional decline. Transfer nurses play a key role in arranging post-discharge geriatric follow-up care. Geriatric consultations are performed by geriatricians, geriatric nurses, and PReCaP case managers in hospital A. Yet hospital B consultative psychiatric nurses provide similar consultation services. The combination of standardized procedures, formalized communication channels, and advanced computerization contributes significantly to geriatric care in hospital B. Nevertheless, a small size hospital (hospital C) provides informal opportunities for information sharing and decision making, which are essential in geriatric care, given its multidisciplinary nature. CONCLUSIONS: Geriatric care for patients with multimorbidity requires a multidisciplinary approach in a geriatric unit. Geriatric care, which integrates medical and reactivation treatment, by means of early screening of risk factors for functional decline, promotion of physical activity, and adequate discharge planning, potentially reduces the incidence of functional decline in elderly patients. Yet low treatment fidelity played a major role in the ineffective implementation of the PReCaP. Treatment fidelity issues are caused by various factors, including the complexity of projects, limited attention for implementation, and inadequate interdisciplinary communication. © 2016 The Authors The International Journal of Health Planning and Management Published by John Wiley & Sons Ltd.

Do determinants of burden and emotional distress in dementia caregivers change over time?

OBJECTIVES: Caring for a patient with dementia is a real challenge and can have considerable psychological consequences in the long run. Many caregivers, mostly relatives, feel highly burdened. To develop effective caregiver support to prevent caregivers from getting overburdened, insight is needed into the determinants of burden. The objective of this study is to explore which patient and caregiver characteristics determine the different kinds of caregiver burden over time, both in the short and in the long run. METHOD: The study was longitudinal. Data on patients and caregivers, general burden and emotional distress were collected at three times: at baseline, at the end of treatment and at nine months. The study was conducted in a psychiatric skilled nursing home with a unit for integrative reactivation and rehabilitation (IRR) and at different sites of home-/day care, assisted living arrangements and nursing home wards (usual care). RESULTS: General burden is shown to be determined by severity of patient's neuropsychiatric symptoms, caregiver's sense of competence, health-related quality of life. Emotional distress is determined by severity of patient's neuropsychiatric symptoms, caregiver's sense of competence, high affiliation and patient gender. CONCLUSION: In preventing or treating caregiver burden, professional interventions need to aim specifically at diminishing the neuropsychiatric symptoms in dementia patients and improving the sense of competence in caregivers.

Community day care with carer support versus usual nursing home-based day care: effects on needs, behavior, mood, and quality of life of people with dementia.

BACKGROUND: Several studies have shown that the combined community-based Meeting Centres Support Programme (MCSP) for people with mild to moderate dementia and their carers were more effective in reducing behavior and mood problems of people with dementia than traditional nursing home-based (NH) day care. We therefore investigated in this study whether community-based (CO) psychogeriatric day care for people with mild to severe dementia combined with carer support (in accordance with the MCSP), is more effective than regular NH day care. METHODS: A pre-test-post-test control group design was used to compare the effect of CO and NH day care on care needs, behavior and mood problems, and quality of life of people with dementia. 138 dyads of people with mild to severe dementia and family carers participated in the study: 70 from (new and longer existing) CO day cares (experimental group), and 68 from NH day cares (control group). ANCOVAs were performed at post-tests, including baseline data as covariates. RESULTS: After six months, no overall differences on outcome measures were found between CO and NH day cares. However, participants of recently started CO day cares showed fewer neuropsychiatric symptoms, whereas carers in the longer existing CO day cares reported fewer care needs compared to the control group (large effects). Persons with dementia cohabiting with their carer benefitted most from CO day care. CONCLUSIONS: This study shows that combined CO day care has promising added value compared to NH day care, especially for participants with dementia cohabiting with their carer.

Formal and informal care costs of hospitalized older people at risk of poor functioning: A prospective cohort study.

Hospitalized older people are at risk of poor functioning after hospital discharge. We aimed to relate formal and informal care costs to level of risk for low functioning of hospitalized older people up to one year after admission. We studied 460 patients 65 years or older who were admitted to a 450-bed hospital in the Netherlands between June 2010 and October 2010. Participants were classified into five risk groups at hospital admission using the Identification Seniors At Risk-Hospitalized Patients (ISAR-HP). Patients were interviewed at hospital admission and at three and twelve months after admission using validated questionnaires to measure health care utilization. Informal caregivers were interviewed by mailed paper questionnaires at the same time as patients. We estimated costs per unit from hospital information systems and nationally representative research. Mean healthcare costs were €30k euro per person per year, with one third for initial hospital stay (€9,8k), one third for formal healthcare costs between hospital discharge and twelve month follow up (€10,3k), and one third for informal healthcare costs between hospital discharge and twelve month follow up (€9,5k). Informal and formal healthcare costs were almost double for people with the highest risk score compared to people not at risk (p<0.001). Older patients with high risk scores at hospital admission have substantially higher formal and informal care costs in the year after initial hospital admission than people with low risk scores. This implies that substantial investments may be made in preventive interventions for at-risk hospitalized older people.

The importance of relational coordination for integrated care delivery to older patients in the hospital.

AIM: This study investigated relational coordination among professionals providing healthcare to hospitalized older patients and assessed its impact on integrated care delivery. BACKGROUND: Previous studies have shown that relational coordination is positively associated with the delivery of acute, emergency and trauma care. The effect of relational coordination in integrated care delivery to hospitalized older patients remains unknown. METHODS: This cross-sectional study was part of an examination of integrated care delivery to hospitalized older patients. Data were collected using questionnaires distributed to hospital professionals (192 respondents; 44% response rate). RESULTS: After controlling for demographic variables, regression analyses showed that relational coordination was positively related to integrated care delivery (ß = 0.20; P ≤ 0.05). Relational coordination was lower among professionals in the same discipline, and higher between nurses and others than between medical specialists and others. Relational coordination and integrated care delivery were significantly higher in geriatrics than in other units (both P ≤ 0.001). CONCLUSIONS: The enhancement of relational coordination among healthcare professionals is positively associated with integrated care delivery to older patients. IMPLICATIONS FOR NURSING MANAGEMENT: Relational coordination should be improved between medical specialists and others and higher levels of relational coordination and integrated care delivery should be achieved in all hospital units.

Multivariate models of subjective caregiver burden in dementia: a systematic review.

BACKGROUND: Burden in dementia caregivers is a complex and multidimensional construct. Several models of burden and other representations of burden like depression or mental health are described in literature. To clarify the state of science, we systematically reviewed complex models that include both patient and caregiver determinants of caregiver burden. OBJECTIVE: A review of determinant models of caregiver burden. DESIGN: Systematic review. DATA SOURCES: Electronic databases PubMed, PsycInfo and EMbase were searched in December 2013. STUDY SELECTION AND ANALYSIS: Research studies with quantitative outcome measures of caregiver burden or burden-related concepts, including both patient and caregiver functional characteristics as determinants. We categorized the determinant variables in the models and calculated the percentages of proven determinants within each category. RESULTS: We found 32 studies with burden models and 24 depression and mental health models. Patient behavioral problems, caregiver coping and personality traits and competence are most consistent determinants of caregiver burden, depression and mental health. Behavioral problems are more significant than cognitive disorders or lack of self-care. Of all measured caregiver personality traits, neuroticism has the strongest impact on caregiver burden. Regarding caregiver competences, feeling competent or enjoying higher self-efficacy in general diminish caregiver burden and promote caregiver mental health.

A framework for understanding outcomes of integrated care programs for the hospitalised elderly.

INTRODUCTION: Integrated care has emerged as a new strategy to enhance the quality of care for hospitalised elderly. Current models do not provide insight into the mechanisms underlying integrated care delivery. Therefore, we developed a framework to identify the underlying mechanisms of integrated care delivery. We should understand how they operate and interact, so that integrated care programmes can enhance the quality of care and eventually patient outcomes. THEORY AND METHODS: Interprofessional collaboration among professionals is considered to be critical in integrated care delivery due to many interdependent work requirements. A review of integrated care components brings to light a distinction between the cognitive and behavioural components of interprofessional collaboration. RESULTS: Effective integrated care programmes combine the interacting components of care delivery. These components affect professionals' cognitions and behaviour, which in turn affect quality of care. Insight is gained into how these components alter the way care is delivered through mechanisms such as combining individual knowledge and actively seeking new information. CONCLUSION: We expect that insight into the cognitive and behavioural mechanisms will contribute to the understanding of integrated care programmes. The framework can be used to identify the underlying mechanisms of integrated care responsible for producing favourable outcomes, allowing comparisons across programmes.

Economic evaluation alongside a single RCT of an integrative psychotherapeutic nursing home programme.

BACKGROUND: There is an 80% prevalence of two or more psychiatric symptoms in psychogeriatric patients. Multiple psychiatric symptoms (MPS) have many negative effects on quality of life of the patient as well as on caregiver burden and competence. Irrespective of the effectiveness of an intervention programme, it is important to take into account its economic aspects. METHODS: The economic evaluation was performed alongside a single open RCT and conducted between 2001 and 2006. The patients who met the selection criteria were asked to participate in the RCT. After the patient or his caregiver signed a written informed consent form, he was then randomly assigned to either IRR or UC.The costs and effects of IRR were compared to those of UC. We assessed the cost-utility of IRR as well as the cost-effectiveness of both conditions. Primary outcome variable: severity of MPS (NPI) of patients; secondary outcome variables: general caregiver burden (CB) and caregiver competence (CCL), quality of life (EQ5D) of the patient, and total medical costs per patient (TiC-P). Cost-utility was evaluated on the basis of differences in total medical costs). Cost-effectiveness was evaluated by comparing differences of total medical costs and effects on NPI, CB and CCL (Incremental Cost-Effectiveness Ratio: ICER). CEAC-analyses were performed for QALY and NPI-severity. All significant testing was fixed at p<0.05 (two-tailed). The data were analyzed according to the intention-to-treat (ITT)-principle. A complete cases approach (CC) was used. RESULTS: IRR turned out to be non-significantly, 10.5% more expensive than UC (€ 36 per day). The number of QALYs was 0.01 higher (non-significant) in IRR, resulting in € 276,290 per QALY. According to the ICER-method, IRR was significantly more cost-effective on NPI-sum-severity of the patient (up to 34%), CB and CCL (up to 50%), with ICERs varying from € 130 to € 540 per additional point of improvement. CONCLUSIONS: No significant differences were found on QALYs. In IRR patients improved significantly more on severity of MPS, and caregivers on general burden and competence, with incremental costs varying from € 130 to € 540 per additional point of improvement. The surplus costs of IRR are considered acceptable, taking into account the high societal costs of suffering from MPS of psychogeriatric patients and the high burden of caregivers. The large discrepancy in economic evaluation between QALYs (based on EQ5D) and ICERs (based on clinically relevant outcomes) demands further research on the validity of EQ5D in psychogeriatric cost-utility studies. (Trial registration nr.: ISRCTN 38916563; December 2004).

Prognosis of hospitalised older people with different levels of functioning: a prospective cohort study.

BACKGROUND: hospitalised older people are at risk for poor functioning after hospital discharge. We aimed to validate the predictive ability of the Identification Seniors At Risk-Hospitalized Patients (ISAR-HP) screening questionnaire to identify older patients at risk for functional dependence by comparing groups with different ISAR-HP scores on cognitive and physical functioning, mortality, health-related quality of life (HRQoL) and loneliness. DESIGN: a longitudinal prospective cohort study. SETTING: a 450-bed hospital in the Netherlands. SUBJECTS: four hundred and sixty patients 65 years or older admitted between June 2010 and October 2010. METHODS: participants were classified into five risk groups at hospital admission using the ISAR-HP. We interviewed patients at hospital admission and at 3 and 12 months after admission using validated questionnaires to score HRQoL, physical functioning, cognitive functioning and loneliness. Differences in survival were quantified by a concordance statistic (c). RESULTS: cognitive functioning, physical functioning, loneliness and HRQoL differed significantly between groups during the 1-year follow-up after hospital admission (all comparisons P < 0.05), with high-risk groups having lower scores than low-risk groups for functioning and loneliness, although not always for HRQoL. The lowest risk group (ISAR-HP = 0) scored consistently higher on functioning and HRQoL than all other groups. Mortality differed significantly between groups (P < 0.001, c = 0.67). CONCLUSIONS: the ISAR-HP can readily distinguish well-functioning older patients from patients with low functioning and low HRQoL after hospital admission. The ISAR-HP may hence assist in selecting patients who may benefit from individually tailored reactivation treatment that is provided next to treatment of their medical condition.

Benefit of an integrative psychotherapeutic nursing home program to reduce multiple psychiatric symptoms of psychogeriatric patients and caregiver burden after six months of follow-up: a re-analysis of a randomized controlled trial.

BACKGROUND: In this paper, we aim to test the long-term benefit of an integrative reactivation and rehabilitation (IRR) program compared to usual care in terms of improved psychogeriatric patients on multiple psychiatric symptoms (MPS) and of caregivers on burden and competence. Improvement was defined as >30% improvement (≥ a half standard deviation) compared to baseline. METHODS: We used the following outcome variables: difference in the number of improved patients on MPS (Neuropsychiatric Inventory, NPI) and improved caregivers on burden (Caregiver Burden, CB) and competence (Caregiver Competence List, CCL). Assessments were taken after intake (T1) and after six months of follow-up (T3). Risk ratios (RR), number needed to treat (NNT), and odds ratios (ORs) were calculated. RESULTS: IRR had a significant positive effect on NPI-cluster hyperactivity (RR 2.64; 95% CI: 1.26-5.53; NNT 4.07). In the complete cases analysis, IRR showed significant ORs of 2.80 on the number of NPI symptoms and 3.46 on the NPI-sum-severity; up to 76% improved patients. For caregivers, competence was a significant beneficiary in IRR (RR 2.23; 95% CI: 1.07-4.62; NNT 5.07). In the complete cases analysis, the ORs were significantly in favor of IRR on general burden and competence (ORs range: 2.40-4.18), with up to 71% improved caregivers. CONCLUSION: IRR showed a significantly higher probability of improvement with a small NNT of four on multiple psychiatric symptoms in psychogeriatric patients. The same applies to the higher probability to improve general burden and competence of the caregiver with an NNT of five. The results were even more pronounced for those who fully completed the IRR program. (Inter)national psychogeriatric nursing home care and ambulant care programs have to incorporate integrative psychotherapeutic interventions.

Integrated approach to prevent functional decline in hospitalized elderly: the Prevention and Reactivation Care Program (PReCaP).

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 an innovative program (PReCaP), 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 (PRC); (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 future papers. TRIAL REGISTRATION: The Netherlands National Trial Register: NTR2317.

Evaluation design of a reactivation care program to prevent functional loss in hospitalised elderly: a cohort study including a randomised controlled trial.

BACKGROUND: Elderly persons admitted to the hospital are at risk for hospital related functional loss. This evaluation aims to compare the effects of different levels of (integrated) health intervention care programs on preventing hospital related functional loss among elderly patients by comparing a new intervention program to two usual care programs. METHODS/DESIGN: This study will include an effect, process and cost evaluation using a mixed methods design of quantitative and qualitative methods. Three hospitals in The Netherlands with different levels of integrated geriatric health care will be evaluated using a quasi-experimental study design. Data collection on outcomes will take place through a prospective cohort study, which will incorporate a nested randomised controlled trial to evaluate the effects of a stay at the centre for prevention and reactivation for patients with complex problems. The study population will consist of elderly persons (65 years or older) at risk for functional loss who are admitted to one of the three hospitals. Data is prospectively collected at time of hospital admission (T0), three months (T1), and twelve months (T2) after hospital admission. Patient and informal caregiver outcomes (e.g. health related quality of life, activities of daily living, burden of care, (re-) admission in hospital or nursing homes, mortality) as well as process measures (e.g. the cooperation and collaboration of multidisciplinary teams, patient and informal caregiver satisfaction with care) will be measured. A qualitative analysis will determine the fidelity of intervention implementation as well as provide further context and explanation for quantitative outcomes. Finally, costs will be determined from a societal viewpoint to allow for cost effectiveness calculations. DISCUSSION: It is anticipated that higher levels of integrated hospital health care for at risk elderly will result in prevention of loss of functioning and loss of quality of life after hospital discharge as well as in lower burden of care and higher quality of life for informal caregivers. Ultimately, the results of this study may contribute to the implementation of a national integrated health care program to prevent hospital related functional loss among elderly patients. TRIAL REGISTRATION: The Netherlands National Trial Register: NTR2317.

Integrative psychotherapeutic nursing home program to reduce multiple psychiatric symptoms of cognitively impaired patients and caregiver burden: randomized controlled trial.

OBJECTIVE: To test the effectiveness of an integrative psychotherapeutic nursing home program (integrative reactivation and rehabilitation [IRR]) to reduce multiple neuropsychiatry symptoms (MNPS) of cognitively impaired patients and caregiver burden (CB). DESIGN: Randomized controlled trial. SETTING: Psychiatric-skilled nursing home (IRR) and usual care (UC), consisting of different types of nursing home care at home or in an institution. PARTICIPANTS: N = 168 (81 IRR and 87 UC). Patients had to meet classification of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition for dementia, amnestic disorders, or other cognitive disorders. Further inclusion criteria: Neuropsychiatric Inventory (NPI) ≥3; Mini-Mental State Examination ≥18 and ≤27; and Barthel Index (BI) ≥5 and ≤19. INTERVENTION: IRR consisted of a person-oriented integrative psychotherapeutic nursing home program to reduce MNPS of the patient and CB. UC consisted of different types of nursing home care at home or in an institution, mostly emotion oriented. MEASUREMENTS: Primary outcome variable was MNPS (number and sum-severity of NPI). Furthermore, burden and competence of caregiver were also measured. ASSESSMENTS: T1 (inclusion), T2 (end of treatment), T3 (after 6 months of follow-up). Cohen's d (Cd) was calculated for mean differences (intention to treat). For confounding, repeated measurement modeling (random regression modeling [RRM]) was applied. RESULTS: In the short term from the perspective of the caregiver, IRR showed up to 34% surplus effects on MNPS of the patients; NPI symptoms: 1.31 lower (Cd, -0.53); and NPI sum- severity: 11.16 lower (Cd, -0.53). In follow-up, the effects were sustained. However, from the perspective of the nursing team, these effects were insignificant, although the trend was in the same direction and correlated significantly with the caregiver results over time (at T3: r = 0.48). In addition, IRR showed surplus effects (up to 36%) on burden and competence of caregiver: NPI emotional distress: 3.78 (Cd, -0.44); CB: 17.69 (Cd, -0.63) lower; and Competence: 6.26 (Cd, 0.61) higher. In follow-up, the effects increased up to 50%. RRM demonstrated that the effects were stable. CONCLUSION: From the perspective of the caregiver, IRR was significantly more effective than UC to reduce MNPS in cognitively impaired patients and CB. In follow-up, the effect on CB even increased. However, from the perspective of the nursing team, the effects on MNPS were statistically insignificant. Nevertheless, the trend was in the same direction and correlated significantly with the caregiver results over time. Further research is needed, preferably using a blinded randomized controlled trial.

Prognostic factors for a favourable long-term outcome from an integrative psychotherapeutic nursing home programme.

BACKGROUND/AIMS: The prevalence of multiple psychiatric symptoms (MPS) in psychogeriatric patients is about 80%. MPS have negative effects on caregivers; 70-80% of caregivers are moderately to heavily burdened. We tested an integrative psychotherapeutic programme (IRR) focused on MPS as well as caregiver burden. To develop decision rules in indicating IRR, prognostic potentialities of diagnostic and functional baseline variables for a favourable outcome of IRR were identified. METHODS: Patients with a DSM-IV classification of dementia, amnestic disorders or other cognitive disorders were followed in a randomised controlled trial, comparing IRR (n=81) with usual nursing home care (n=87). Assessments at T1 (intake) and T2 (6 months' follow-up). RESULTS: In the combined prognostic models Alzheimer dementia showed significant prognostic qualities for improvement on NPI sum severity (OR 3.01), IRR on general burden and competence of caregiver (OR 2.29 and 3.34). Cognitive functions had low prognostic value. CONCLUSION: Prognostic modelling of positive change on severity of MPS and caregiver burden was feasible. Applying three decision rules, all resulted in IRR as indicated intervention. It seems justified to refer psychogeriatric patients suffering from a broad range of cognitive function disorders, specifically patients with dementia of the Alzheimer type, to the IRR programme.