[Death after a fall in patients with advanced dementia: cause of death natural or unnatural?] / Overleden na een val bij gevorderde dementie.

OBJECTIVE: This article describes and discusses the viewpoints of elderly care physicians and municipal coroners regarding the qualification of natural or unnatural deaths of nursing home residents with advanced dementia who fall. DESIGN: A digital questionnaire was sent to all elderly care physicians-in-training and their trainers in the Netherlands, and to all 23 municipal coroners in the Mid-Holland region. METHOD: As well as questions on knowledge of the Dutch law and prognostic figures concerning dementia-related death, the questionnaire described two cases with minimal differences. The respondents were asked if they would issue a certificate of natural death in each case, and if not, would they have preferred to do so. They were also asked to explain their answers. RESULTS: Of the 405 elderly care physicians who responded, 68% and 49%, respectively, would have issued a certificate stating the cause to be natural death in each case, or if they did not they would have preferred to do so. All 15 coroners who filled in the questionnaire came to the conclusion of unnatural death. CONCLUSION: The majority of the elderly care physicians feel that a certificate of natural death can be issued if a fall in a nursing home results in a fracture, as this can be considered as part of the disease process of dementia.

[Vitamin D supplementation in the elderly: guidelines and practice]. / Vitamine D-suppletie bij ouderen: advies en praktijk.

OBJECTIVE: In 2008, the Health Council of the Netherlands published an advice on vitamin D supplementation for the elderly. Nevertheless, suspicion arose at the Ministry of Health, Welfare and Sport and the Netherlands Nutrition Centre that vitamin D supplementation in the elderly is still insufficient. We aimed to determine the extent to which general practitioners and elderly care physicians actually followed the advice of the Health Council. DESIGN: Questionnaire study. METHOD: Brief questionnaires were sent to all elderly care physicians in the Netherlands. Some questions were also posed to general practitioners at a network meeting of the Academic Network of GP Practices of the VU University Medical Center in Amsterdam. RESULTS: More than two-thirds of the respondents, both elderly care physicians and general practitioners, are familiar with the guidelines of the Health Council of the Netherlands on vitamin D supplementation in the elderly, but about half do not prescribe vitamin D when the guideline advises to do so. When supplementation is prescribed, about half of the elderly care physicians and a fifth of the general practitioners uses an insufficient dose. CONCLUSION: The guidelines of the Health Council of the Netherlands on vitamin D supplementation in the elderly are not sufficiently followed by elderly care physicians and general practitioners. Awareness of and support for the vitamin D supplementation guidelines among health care providers is still limited.

Prevention and treatment of vitamin D deficiency in Dutch psychogeriatric nursing home residents by weekly half-body UVB exposure after showering: a pilot study.

BACKGROUND: in older people, induction of cutaneous vitamin D production by ultraviolet B (UVB) exposure may be preferable to oral supplementation: it cannot cause toxic levels, it helps to prevent polypharmacy and, moreover, there are indications that UVB exposure has beneficial effects on health and well being by mechanisms other than the vitamin D pathway alone. OBJECTIVE: the aim of this pilot study is to investigate whether weekly, half-body, UVB irradiation after showering can increase serum 25-hydroxyvitamin D (25(OH)D) to sufficient levels, in a Dutch psychogeriatric nursing home population. METHOD: subjects were eight psychogeriatric nursing home patients, mean age: 79 ± 8. Exclusion criteria were going outdoors into the sun more than once a week, the presence of actinic or cancer skin lesions and known resistance to body contact. The intervention consisted of weekly half-body UVB irradiation, after showering, over 8 weeks, with 0.5 minimal erythemal dose (MED). Main outcome measures were change in fasting serum levels of 25(OH)D and parathyroid hormone (PTH) at 0, 2, 4 and 8 weeks. RESULTS: at baseline, mean serum 25(OH)D was 28.5 nmol/l. Mean serum 25(OH)D levels increased to 46.5 nmol/l. Median serum PTH levels decreased by 20% after 8 weeks of treatment. CONCLUSION: an 8 week course of weekly, frontal half-body irradiation with UVB, at 0.5 MED, leads to an significant increase in 25(OH)D serum levels, but this period is too short to reach vitamin D sufficiency.

[Summary of 'Decubitus' guideline of the Dutch College of Family Practitioners]. / Samenvatting van de standaard 'Decubitus' van het Nederlands Huisartsen Genootschap.

The guideline 'Decubitus' published by the Dutch College of General Practitioners contains guidelines with instructions for prevention, diagnosis and treatment of pressure ulcers in primary care. The classification used for severity is: redness of the skin, superficial damage, superficial ulcer, deep ulcer. This classification follows the one used internationally and the one in the consensus of the Dutch Institute for Health Care Improvement CBO. For each patient who becomes (totally or partly) immobile measures to prevent pressure ulcers are necessary, with emphasis on minimizing pressure and shearing forces acting upon the skin. After a pressure ulcer has developed these measures remain important. Guidelines for treatment are given for each level of severity of the pressure ulcer; the main aim is to keep the ulcer moist, to remove necrosis and exudate and to treat infection.

Ultraviolet irradiation corrects vitamin D deficiency and suppresses secondary hyperparathyroidism in the elderly.

The objective of this study was to compare the effect of ultraviolet radiation (UV) and oral vitamin D3 on the vitamin D status and parathyroid hormone (PTH) concentration in elderly nursing home patients. The design of the study was a randomized clinical trial. The setting was a psychogeriatric nursing home. Subjects included 45 female psychogeriatric patients with a mean age of 85 years. Exclusion criteria were going outdoors more than once a week and the presence of actinic or cancer skin lesions. Intervention was random allocation of UV-B irradiation at half the minimal erythemal dose of the lower back, three times per week during 12 weeks (UV-B), or oral vitamin D3 400 IU/day during 12 weeks (VIT-D), or no treatment (CONTR). Main outcome measures were change in fasting serum levels of vitamin D metabolites at 0, 2, 4, 8, and 12 weeks in the treatment groups, compared with the control group. PTH(1-84) was measured at 0 and 12 weeks. Baseline serum 25-hydroxyvitamin D (25(OH)D) was lower than 30 nmol/l in 95% of the participants. It increased to a median value of around 60 nmol/l after 12 weeks both in the UV-B and VIT-D groups, whereas there was no change in the CONTR group. Serum 1,25-dihydroxyvitamin D increased significantly in the UV-B group. Serum calcium increased significantly in both treatment groups. Serum PTH decreased more than 30% in both treatment groups (p < 0.001), whereas there was no significant change in the control group. Irradiation with UV-B in the very elderly for a few minutes per day leads to adequate improvement of the vitamin D status. It is as effective as oral vitamin D3 in increasing serum 25(OH)D and suppressing secondary hyperparathyroidism.

[Multiple pulmonary embolisms in nursing home patients recognizable by alertness to certain aspecific symptoms]. / Multipele longembolieën bij verpleeghuispatiënten herkenbaar door alertheid op bepaalde aspecifieke symptomen.

OBJECTIVE: To determine whether increased alertness regarding multiple pulmonary embolism in geriatric patients increases the number of cases diagnosed. DESIGN: Retrospective descriptive study. SETTING: Dutch nursing homes Mariënhaven (psychogeriatric) in Warmond and De Wilbert (somatic and psychogeriatric) in Katwijk aan den Rijn, the Netherlands. METHOD: In the period 1989-1991, the diagnosis of multiple pulmonary embolism was suspected in 15 patients with an 'unclear' or 'aspecific' complex of symptoms, who subsequently underwent ventilation perfusion scintigraphy. RESULTS: In 11/15 patients the diagnosis of multiple pulmonary embolism was confirmed. These patients were treated with anticoagulants resulting in complete recovery in 9 patients. Aspecific symptoms suggestive of pulmonary embolism include subfebrile temperature, respiratory and sensory disturbances and a clinical picture mimicking airway infection. If lung scintigraphy is only performed if a positive diagnosis will have the therapeutical consequences for the patients concerned, and assuming that refraining from treatment would lead to death, it was calculated that on a yearly basis mortality in subjects in nursing homes could be reduced by more than 2% when appropriate diagnosis is made and treatment given. Comparison of the data from SIG Health Information (Utrecht) with the present results suggests that the prevalence of (multiple) pulmonary embolism in the Dutch nursing homes is insufficiently recognized. CONCLUSION: More alertness regarding multiple pulmonary embolism in nursing home patients will establish the diagnosis more frequently and proper treatment of this condition will lead to a decrease in mortality.