[Rivastigmine as treatment for flashbacks and REM sleep problems in an older patient]. / Rivastigmine tegen herbelevingen en remslaapstoornissen bij een oudere patiënte.

A 61-year-old woman with suspected schizophrenia has been attending an outpatient geriatrics service for some time, initially with memory complaints and panic attacks. During treatment, the diagnosis schizophrenia was rejected and psychopharmaceuticals were largely phased out, which improved cognitive functions. Eventually, flashbacks of incest experienced in childhood remained together with REM sleep pathology. The flashbacks, nightmares and the REM sleep pathology were responsive to rivastigmine. Rivastigmine use for the treatment of REM sleep pathology is known in the literature, but it has never been described previously that rivastigmine also impacts on flashbacks and nightmares..

Implementation of point-of-care testing and a temporary influenza ward in a Dutch hospital.

BACKGROUND: The seasonal influenza epidemic poses a significant burden on hospitals, both in terms of capacity and costs. Beds that are occupied by isolated influenza patients result in hospitals temporary being closed to admissions and elective operations being cancelled. Improving hospital and emergency department (ED) patient flow during the influenza season could solve these problems. Microbiological point-of-care-testing (POCT) could reduce unnecessary patient isolation by providing a positive/negative result before admission, but has not yet broadly been implemented. METHODS: A clinical pathway for patients with acute respiratory tract infection presenting at the ED was implemented, including a PCR-based POCT for influenza, operated by nurses and receptionists. In parallel, a temporary ward equipped with 15 beds for influenza-positive patients was established. In this retrospective observational study, we describe the results of implementing this pathway by comparison with the previous epidemic. RESULTS: Clinical performance of the POCT within the clinical pathway was good with strongly decreased time from ED presentation to sample collection (194 vs 47 min) and time from sample collection to result (1094 vs 62 min). Hospital patient flow was improved by a decreased percentage of admitted influenza-positive patients (91% vs 73%) and shorter length of subsequent stay (median 5.86 vs 4.61 days) compared to the previous influenza epidemic. In addition, 430 patient-days of unnecessary isolation have been prevented within a time span of 18 weeks. Roughly estimated savings were almost 400,000 euros. CONCLUSION: We recommend that hospitals explore possibilities for improving patient flow during an influenza epidemic.

[Not every delirium protocol in Dutch hospitals is up-to-date: evaluation of the implementation of the new delirium guideline]. / Niet elk delierprotocol in ziekenhuizen is up-to-date.

OBJECTIVE: To describe the extent to which the essential changes in the new Dutch delirium guideline for adults and the elderly, published in April 2014, have been incorporated in local hospital protocols, so as to estimate the consequences this could have for patients. DESIGN: Quantitative study. METHOD: Dutch hospital protocols were collected for two periods: before (September to December 2012) and after publication of the guideline (March to July 2015). Protocols were compared with respect to basic delirium care (screening, diagnostic approach, therapy and follow-up care) and organisation of care. RESULTS: Of the 80 Dutch hospitals approached, we were able to include 57 (71%) protocols in this study. 16 hospitals (28%) had adapted their protocols to the new guideline. Screening for the risk of delirium using the questions from the Dutch safety management system (Veiligheidsmanagementsysteem) was described in 29 (51%) of the protocols. Use of the Delirium Observation Screening Scale was reported in 52 (91%) protocols. A policy of moderation regarding antipsychotic therapy was described in 12 of 53 (23%) protocols, but in 21/53 (40%) the haloperidol dosages were higher than advised by the guideline. Follow-up care is described in 40 (70%) of the protocols. Organisation of delirium care, for example restriction of consultation of an expert to complex cases, was advised in 33/57 (58%) protocols. CONCLUSION: 15 months after publication, only just over a quarter of the protocols incorporated the guideline. In terms of the treatment of patients with delirium, this may have led to unnecessary treatment with antipsychotics. Furthermore, basic delirium care is apparently still not considered as the responsibility of every medical specialist in the hospital.

[Discussing the resuscitation policy at a geriatric ward: the experience of patients or their representatives]. / Bespreken van het reanimatiebeleid op een afdeling geriatrie: de ervaring van patiënt en familie.

AIM: To identify geriatric patients' and their surrogate decision makers' experience with regard to discussing cardio pulmonary resuscitation (CPR) policy. METHODS: This is a prospective, observational, explorative survey. During 10 weeks, all patients admitted to a geriatric ward of a general Dutch hospital or their representatives were asked for their experience regarding discussion of the resuscitation policy with the physician in attendance. Discussing this policy is a standard procedure at the first day of admission. We also asked on several factors which could influence their experience and on factors to improve discussing resuscitation policies. The primary outcome was the participant's satisfaction expressed on a scale of 1 to l0 regarding satisfaction with the CPR discussion. RESULTS: Seventy-six participants were included, of which 29 patients and 47 surrogate decision makers. Discussing the resuscitation policy took an average of 4,5 minutes (SD 3.2) to complete. In 70% (n=53) of cases a do-not-resuscitate decision was made. Discussing the resuscitation policy was experienced positive, with an average rate of 7,8 (SD 1.5). A total of 121 positive comments were made, as opposed to 70 negative comments. When they talked about their resuscitation policy, most patients expressed positive emotional responses. As most important improvements were mentioned: a better introduction to discussing this subject (17%), a better explanation of resuscitation and chances of survival (17%) and providing information prior to admission to the ward, so that patient and surrogate decision maker have been informed that the resuscitation policy will be discussed (12%). CONCLUSION: Most patients and relatives in this study wished to discuss their resuscitation policy with physicians. Still, there is room for improvement in several respects. Patients and surrogate decision makers are in favour of discussing the standard resuscitation policy with the doctor, and evaluate this conversation with a 7.8 / 10. In order to improve both discussing the CPR policy preparing the patient and his representatives and communicating more extensively during the interview are recommended.

[Oral galantamine versus rivastigmine transdermal patch: a descriptive study at a memory clinic in The Netherlands]. / Galantamine of rivastigmine pleister. Een beschrijvend onderzoek op een geheugenpolikliniek in Nederland.

OBJECTIVES: Since January 2008 in The Netherlands, two cholinesterase inhibitors, oral galantamine and rivastigmine transdermal patch, are registered as a one-day symptomatic treatment for Alzheimer's disease. As no head to head study was performed yet, the objective of this study was to describe the daily practice of oral galantamine and rivastigmine transdermal patch in a real life population of a memory clinic of a suburban teaching hospital in The Netherlands. METHODS: A randomized open label study in 84 ambulant Alzheimer's patients with at least 6 months follow-up and treated either with oral galantamine (group G) or rivastigmine transdermal patch (group R). Data collection included patients' demographic and disease variables. Adverse events were collected and, in case of interruption of the primary treatment, the alternative treatment was registered. RESULTS: Serious adverse events did not occur. In group G respectively group R adverse events occurred in 20 patients (50%) and 18 patients (41%). No difference occurred in the frequency of nausea or vomiting. In group R more patients noted dermatological adverse events. In group G respectively group R medication was stopped in 12 patients (30%) and 14 patients (32%). However, compared to group G after stopping the treatment in group R more patients received a new anti-dementia medication (respectively 11 patients (79%) and 4 patients (33%)) (chi2(1) = 5.418, p = .026). CONCLUSION: Despite different forms, the use of oral galantamine and rivastigmine transdermal patch showed neither difference in the frequency of adverse events neither in the frequency of stopping primary treatment. However, compared to oral galantamine use, rivastigmine transdermal patch resulted in more dermatological adverse events and after stopping rivastigmine transdermal patch, new anti-dementia medication or form was more often started. More research is urgently needed.

[Applicability and validity of the Dutch version of the Montreal Cognitive Assessment (moCA-d) in diagnosing MCI]. / Bruikbaarheid en validiteit van de Nederlandse versie van de Montreal Cognitive Assessment (MoCA-D) bij het diagnosticeren van Mild Cognitive Impairment.

OBJECTIVE: The MoCA is a new screening test to detect Mild Cognitive Impairment (MCI). Purpose of this study is validating the Dutch version (MoCA-D). METHOD: We administered the MoCA-D to healthy control subjects and to elderly with MCI or dementia from a memory disorder outpatient clinic and a geriatric (outpatient) clinic (n = 30, 32, 37 respectively, age > or = 60). Neuropsychological testing was part of the standard procedure for patients to diagnose MCI. Sensitivity, specificity and predictive values (positive: PPV and negative: NPV) of the MoCA-D were assessed. RESULTS: A significant effect of group was found on MoCA-D total score (F (2.95) =67.9; p < 0.01). With a cutoff score of < or = 25, sensitivity and specificity to detect MCI in relation to healthy controls were 72% and 73%, respectively. PPV and NPV were 84% and 56%, respectively. With a cut-off score of < or = 20, sensitivity to detect dementia in relation to MCI was 100% for severe dementia and 75% for mild dementia. Specificity for dementia was 81%, PPV 94% and NPV 55%. CONCLUSION: The MoCA-D distinguishes between healthy elderly, MCI patients and dementia patients. However, in this study, insufficient sensitivity and poor specificity were found. For the present, applying a broader and flexible screening procedure in order to detect MCI seems a more useful method than the interpretation of one test result in particular.

[Progressive supranucleair palsy: acetylcholineeserase-inhibitor a possible therapy?]. / Progressieve Supranucleaire Verlamming. Interventie middels acetylcholineesteraseremmer?

Progressive supranucleair palsy (PSP) is a serious neurologic disease which is seldom diagnosed due to its complexity. In 1996 international diagnostic criteria were developed by a group of experts, the diagnosis remains complicated. We describe three cases, which were followed in the period 2001-2008. In these case reports we elaborate on the therapeutic use of rivastigmine. During off-label rivastigmine use, patients showed minimal further cognitive decline, specifically with respect to frontal defects. However, larger studies and trials are necessary to explore the effects of rivastigmine in patients with PSP.

[A triage system for non-urgent ambulant frail elderly]. / Triage in de niet acute ouderengeneeskunde: geriater, arts-assistent geriatrie of valpolikliniek. Een praktijkvoorbeeld.

PURPOSE: This study aimed to examine a triage system for non-urgent ambulant frail elderly. METHODS: Three months prospective evaluation of patients, admitted for an out-hospital evaluation on a geriatric ward of an non-academic teaching hospital and not suitable for a memory clinic or falls clinic. A maximum of four patients entered the triage system at the same moment and a nurse and a physiotherapist investigated these patients separately during 30 minutes in total. After these investigations, triage consensus was reached and immediately thereafter, 2 patients were admitted to a fall clinic, 1 patient was admitted to a consultant and 1 patient was admitted to a resident. For each admission, there were positive and negative reasons defined. RESULTS: During 22 moments of triage, 68 patients were admitted to the different out-hospital evaluations. In 90% positive reasons for triage were used. CONCLUSIONS: A triage system for non-urgent ambulant frail elderly seems to be effective. However, more research is needed.

[The possible value of diagnosing MCI-DLB and treatment options]. / Vroeg optredende symptomen van Dementie met Lewy Bodies: de waarde van de diagnose MCI-DLB en de mogelijke behandeling.

Dementia with Lewy Bodies (DLB) is a well-described clinical entity. DLB patients can be treated with acetylcholinesterase inhibitors (AChEI's). However, should we also treat patients who have but part of the symptoms and who are currently described as MCI-DLB? Will these MCI-DLB patients benefit from AChEI's in terms of direct effect on cognition and behaviour and final outcome? Two cases are presented to demonstrate the clinical features of MCI-DLB and the effect of treatment with rivastigmine (AChEI). The discussion then focuses on the possible value of diagnosing MCI-DLB and if this diagnosis should result in a different medication treatment than the diagnosis MCI-AD, for which AChEI medication is not recommended.

[Delirium after a fractured hip in more than one-third of the patients]. / Delier na een heupfractuur bij ruim een derde van de patiënten.

OBJECTIVE: Inventarisation and evaluation of the incidence, risk factors, and prognosis of postoperative delirium in patients with a fractured hip admitted to a surgical ward. DESIGN: Descriptive study of patient records. METHOD: All patients with a fractured hip admitted to the surgical ward of the Jeroen Bosch Hospital, Den Bosch, the Netherlands, in 2004 were included and evaluated. Active multidisciplinary interventions for the recognition and treatment of delirium by non-pharmacological and pharmacological means take place in this surgical ward. The records of all patients from the surgical and geriatric wards were evaluated and the data were analysed statistically by means of univariate and multivariate logistic 'step-forward' regression analysis. RESULTS: 114 patients were included. The incidence of postoperative delirium was 37%. Older age was a significant risk factor for the development of delirium in both the univariate and the multivariate analysis after correcting for overestimation (p < 0.01). Several other factors, including sex, type of surgery, and medical history, had no effect on the risk of delirium. CONCLUSION: Delirium after a hip fracture is not rare; the most important risk factor is older age.

[Rivastigmine as adjunctive therapy in the therapeutic dilemma for the treatment of hallucinations due to Parkinson disease]. / Rivastigmine als ondersteuning bij het dilemma van de behandeling van hallucinaties optredend bij ziekte van Parkinson.

We report three cases of patients with Parkinson's disease without dementia, admitted to our hospital because of hallucinations. The anti-Parkinson medication was adapted and the patients started with rivastigmine. As a result, hallucinations no longer occurred. A 79 years old man also required short-term quetiapine because of agitation and anti-Parkinson doses were without side effects, as a result of which mobility improved. An 84 years old woman reported mild side effects of rivastigmine, without consequences, whereas her mobility appeared to be good. A 72 years old woman reported mild memory problems upon admission, which improved during admission, as did her mobility after increasing the anti-Parkinson medication doses. Treatment of rivastigmine can be useful in the therapeutic dilemma in the treatment of hallucinations in patients with Parkinson's disease (start anti-psychotic or reduce anti-Parkinson medication). In addition to adapting anti-Parkinson doses and sometimes short-term treating with an anti-psychotic, treatment with rivastigmine appears to be a quick improvement, without serious side effects. Also, mobility can improve, due to the possibility of increasing the anti-Parkinson doses, if necessary. Because of the many remaining questions, prospective randomised trials are needed.

[Fear of falling in a fall clinic for geriatric patients: a pilot study]. / Angst voor vallen op een valpolikliniek geriatrie: een pilotstudy.

OBJECTIVE: In this pilot study we want to determine how often fear of falling occurs in geriatric patients visiting a fall clinic and to study the characteristics of fear of falling and its consequences. DESIGN: Retrospective study of patient's records. METHOD: A random sample of 100 medical records of geriatric patients of the fall clinic of the Jeroen Bosch Ziekenhuis in Den Bosch was systematical examined. RESULTS: The mean age of the patients was 79.8 +/- 6 years. Before visiting the fall clinic, the patients had a history of falling during 34.6 months, and 62% of them visited a hospital due to the consequences of falling. In the fall clinic a mean number of 2.5 probable causes per fall was diagnosed. In this study 31% of the patients had fear of falling. The demographic characteristics and the causes of falling of the patients with or without fear of falling, were almost the same. Patients with fear of falling had a hip prothesis in 26%, whereas patients without fear of falling only in 7% had a hip prothesis (P < 0.05). In patients with fear of falling, in 90% extra diagnostic investigation was needed, whereas in patients without fear of falling extra diagnostic investigation only occurred in 53% (P < 0.01). Finally, patients with fear of falling needed 1.8 more times physical therapy compared to patients without fear of falling (P < 0.01). CONCLUSION: After a fall, fear of falling occurs often in geriatric patients. In this study, no causes for fear of falling could be determinated, although hip prothesis are associated with fear of falling. In patients with fear of falling more medical consumption occurs. In medical practice as in science fear of falling needs more attention.

Angst voor vallen op een valpolikliniek geriatrie: een pilotstudy.

Fear of falling in a fall clinic for geriatric patients: a pilot study Objective. In this pilot study we wantto determine how often fear of falling occurs in geriatric patients visiting a fall clinic and to study the characteristics of fear of falling and its consequences.Design. Retrospective study of patient's records.Method. A random sample of 100 medical records of geriatric patients of the fall clinic of the Jeroen Bosch Ziekenhuis in Den Bosch was systematical examined.Results. The mean age of the patients was 79.8 ± 6 years. Before visiting the fall clinic, the patients had a history of falling during 34.6 months, and 62% of them visited a hospital due to the consequences of falling. In the fall clinic a mean number of 2.5 probable causes per fall was diagnosed.In this study 31% of the patients had fear of falling. The demographic characteristics and the causes of falling of the patients with or without fear of falling, were almost the same. Patients with fear of falling had a hip prothesis in 26%, whereas patients without fear of falling only in 7% had a hip prothesis (P<0.05). In patients with fear of falling, in 90% extra diagnostic investigation was needed, whereas in patients without fear of falling extra diagnostic investigation only occurred in 53% (P<0.01). Finally, patients with fear of falling needed 1.8 more times physical therapy compared to patients without fear of falling (P<0.01).Conclusion. After a fall, fear of falling occurs often in geriatric patients. In this study, no causes for fear of falling could be determinated, although hip prothesis are associated with fear of falling. In patients with fear of falling more medical consumption occurs. In medical practice as in science fear of falling needs more attention.

A randomized trial of risperidone, placebo, and haloperidol for behavioral symptoms of dementia.

OBJECTIVE: To compare effects of risperidone with placebo (efficacy and tolerability) and haloperidol (tolerability) for treating demented patients with aggression and other behavioral symptoms. METHODS: A 13-week double-blind study involving 344 patients with dementia randomly assigned to receive placebo or flexible doses (0.5 to 4 mg/d) of risperidone or haloperidol. Behavioral symptoms were assessed by the Behavior Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD), the Cohen-Mansfield Agitation Inventory (CMAI), and the Clinical Global Impression (CGI) scale. Tolerability assessments included the Extrapyramidal Symptom Rating Scale, sedation levels, Functional Assessment Staging, Mini-Mental State Examination, and incidence of adverse events. RESULTS: The mean dose at endpoint was 1.1 mg/d of risperidone and 1.2 mg/d of haloperidol. Although not significant, a higher percentage of patients receiving risperidone than those receiving placebo showed clinical improvement (> or =30% reduction from baseline to endpoint in BEHAVE-AD total score) at endpoint and week 12. Reductions in the BEHAVE-AD total score were significantly greater with risperidone than with placebo at week 12. In a further analysis of aggression, the most dominant symptom in these patients, BEHAVE-AD and CMAI aggression cluster scores were significantly reduced compared with placebo at endpoint and week 12. CGI scores were also significantly reduced at endpoint and week 12. Severity of extrapyramidal symptoms with risperidone did not differ significantly from that of placebo and was less than that of haloperidol. A post hoc analysis showed significantly greater reductions in the BEHAVE-AD aggressiveness score with risperidone than haloperidol at week 12. CONCLUSION: Low-dose risperidone (mean 1.1 mg/d) was well tolerated and associated with reductions in the severity and frequency of behavioral symptoms, particularly aggression, in elderly patients with dementia.

Dementia in resuscitation policy: a prospective study of a psychogeriatric ward in a Dutch general teaching hospital.

Resuscitation decisions during the first 6 weeks were analysed for 97 admissions to a psychogeriatric ward of a general teaching hospital. Seventy-seven patients (79%) had a written 'do not resuscitate' (DNR) order on admission and 74 patients (875) had a written DNR order after 6 weeks. Morbidity was assessed with a pre-arrest morbidity (PAM) index and a modified PAM index (MPI). Dementia influenced the presence of a DNR order, both because lack of effectiveness of CPR and lack of quality of life. Age was related to a DNR order. The MPI was associated with the presence of a written DNR order, while the PAM score failed to reach significance. Six weeks after admission DNR orders were predictable by the four variables of dementia, the use of antidepressants, age and PAM, in that order. The association of the use of antidepressants with the presence of a written DNR order was surprising. The use of antidepressants is not the same as the diagnosis of depression. Because of the design, our results cannot permit any conclusion whether depression acts as an additional factor considered in decision-making in psychogeriatric patients. We suggest that depression and its correlates should be considered in discussions and studies about DNR.