The Living Lab In Ageing and Long-Term Care: A Sustainable Model for Translational Research Improving Quality of Life, Quality of Care and Quality of Work.

There is a strong need in long-term care for scientific research, so older people and their families, health care professionals, policy makers, and educators can benefit from new advancements and best available evidence in every day care practice. This paper presents the model of a sustainable and successful interdisciplinary collaboration between scientists, care providers and educators in long-term care: the "Living Lab in Ageing and Long-Term Care" by Maastricht University in the Netherlands. Its mission is to contribute with scientific research to improving i) quality of life of older people and their families; ii) quality of care and iii) quality of work of those working in long-term care. Key working mechanisms are the Linking Pins and interdisciplinary partnership using a team science approach, with great scientific and societal impact. A blueprint for the model is discussed, describing its business model and challenges in getting the model operational and sustainable are discussed.

Can the Combined Use of Two Screening Instruments Improve the Predictive Power of Dependency in (Instrumental) Activities of Daily Living, Mortality and Hospitalization in Old Age?

BACKGROUND: Due to differences in the definition of frailty, many different screening instruments have been developed. However, the predictive validity of these instruments among community-dwelling older people remains uncertain. OBJECTIVE: To investigate whether combined (i.e. sequential or parallel) use of available frailty instruments improves the predictive power of dependency in (instrumental) activities of daily living ((I)ADL), mortality and hospitalization. DESIGN, SETTING AND PARTICIPANTS: A prospective cohort study with two-year follow-up was conducted among pre-frail and frail community-dwelling older people in the Netherlands. MEASUREMENTS: Four combinations of two highly specific frailty instruments (Frailty Phenotype, Frailty Index) and two highly sensitive instruments (Tilburg Frailty Indicator, Groningen Frailty Indicator) were investigated. We calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for all single instruments as well as for the four combinations, sequential and parallel. RESULTS: 2,420 individuals participated (mean age 76.3 ± 6.6 years, 60.5% female) in our study. Sequential use increased the levels of specificity, as expected, whereas the PPV hardly increased. Parallel use increased the levels of sensitivity, although the NPV hardly increased. CONCLUSIONS: Applying two frailty instruments sequential or parallel might not be a solution for achieving better predictions of frailty in community-dwelling older people. Our results show that the combination of different screening instruments does not improve predictive validity. However, as this is one of the first studies to investigate the combined use of screening instruments, we recommend further exploration of other combinations of instruments among other study populations.

[Treatment of hypoactive delirium: is there a place for antipsychotics?] / Behandeling van een stil delier.

Hypoactive delirium is common among older hospitalised patients: between 29 and 64% of all older patients in hospital develop a delirium, of which the majority is of the hypoactive subtype. Hypoactive delirium often remains undiagnosed or is only diagnosed late and prognosis is worse than for a hyperactive delirium. Psychotic symptoms, fear, and distress are as frequent in hypoactive as in hyperactive delirium. The guideline of the Dutch College of General Practitioners and the multidisciplinary guideline of the Dutch Geriatrics Society differ in their advice on the pharmacological treatment of hypoactive delirium. Research into the effectiveness of antipsychotics so far did not differentiate between the different types of delirium. In patients with hypoactive delirium, antipsychotics should only be considered after all non-pharmacological options have been tried, no obvious and solvable cause for the delirium has been found and the patient is visibly suffering from the psychotic symptoms.

[Detection and prevention in later life: risk profiles for physical, psychological, social and environmental frailty.] / Detectie en preventie van kwetsbaarheid: Op zoek naar risicoprofielen voor fysieke, psychische, sociale en omgevingskwetsbaarheid.

In order to provide proactive care and support for older people attention is needed for the prevention of frailty among older adults. Subsequently, accurate case finding of those who are more at risk of becoming frail is crucial to undertake specific preventive actions. This study investigates frailty and risk profiles of frailty among older people in order to support proactive detection. Hereby, frailty is conceived not only as a physical problem, but also refers to emotional, social, and environmental hazards. Using data generated from the Belgian Ageing Studies (N = 21,664 home-dwelling older people), a multinomial logistic regression model was tested which included socio-demographic and socio-economic indicators as well as the four dimensions of frailty (physical, social, psychological and environmental). Findings indicate that for both men and women having moved in the previous 10 years and having a lower household income are risk factors of becoming multidimensional frail. However, studying the different frailty domains, several risk profiles arise (e. g. marital status is important for psychological frailty), and gender-specific risk groups are detected (e. g. non-married men). This paper elaborates on practical implications and formulates a number of future research recommendations to tackle frailty in an ageing society.

Validity, Reliability and Feasibility of Tools to Identify Frail Older Patients in Inpatient Hospital Care: A Systematic Review.

BACKGROUND: The objective of this study is to identify and review screening tools for frailty in older adults admitted to inpatient hospital care with respect to their validity, reliability and feasibility. METHODS: Studies were identified through systematically searching PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase and PsycINFO and screening reference lists till June 2014. Papers dealing with screening tools aimed at identifying frail older patients in in-hospital care, and including information about validity, reliability or feasibility, were included in the review. The quality of the included studies was critically appraised via the Quality Assessment of Diagnostic Accuracy Studies (QUADAS). RESULTS: From the originally identified 2001 studies 32 studies met the inclusion criteria, in which 16 screening tools were presented. The screening tools showed different characteristics with respect to the number of items, the method of administration and the domains included. The most frequently studied tools with respect to predictive validity were the Identification Seniors At Risk (ISAR) and Triage Risk Stratification Tool (TRST). Studies retrieved poorer information about reliability and feasibility. Overall sensitivity was fairly good. The ISAR, ISAR-HP (Identification Seniors At Risk Hospitalized Patients) and Multidimensional Prognostic Index (MPI) generally had the best sensitivity. CONCLUSIONS: Many screening tools are available for daily practice. These tools to identify frail older patients in inpatient hospital care could be useful. For no tool, however, is clear evidence available yet regarding validity, reliability and feasibility. The overall sensitivity of the included screening tools was fairly good, whereas information on reliability and feasibility was lacking for most tools. In future research more attention should be given to the latter items.

Validation of the Care-Related Quality of Life Instrument in different study settings: findings from The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS).

PURPOSE: Validity is a contextual aspect of a scale which may differ across sample populations and study protocols. The objective of our study was to validate the Care-Related Quality of Life Instrument (CarerQol) across two different study design features, sampling framework (general population vs. different care settings) and survey mode (interview vs. written questionnaire). METHODS: Data were extracted from The Older Persons and Informal Caregivers Minimum DataSet (TOPICS-MDS, www.topics-mds.eu ), a pooled public-access data set with information on >3,000 informal caregivers throughout the Netherlands. Meta-correlations and linear mixed models between the CarerQol's seven dimensions (CarerQol-7D) and caregiver's level of happiness (CarerQol-VAS) and self-rated burden (SRB) were performed. RESULTS: The CarerQol-7D dimensions were correlated to the CarerQol-VAS and SRB in the pooled data set and the subgroups. The strength of correlations between CarerQol-7D dimensions and SRB was weaker among caregivers who were interviewed versus those who completed a written questionnaire. The directionality of associations between the CarerQol-VAS, SRB and the CarerQol-7D dimensions in the multivariate model supported the construct validity of the CarerQol in the pooled population. Significant interaction terms were observed in several dimensions of the CarerQol-7D across sampling frame and survey mode, suggesting meaningful differences in reporting levels. CONCLUSIONS: Although good scientific practice emphasises the importance of re-evaluating instrument properties in individual research studies, our findings support the validity and applicability of the CarerQol instrument in a variety of settings. Due to minor differential reporting, pooling CarerQol data collected using mixed administration modes should be interpreted with caution; for TOPICS-MDS, meta-analytic techniques may be warranted.

A systematic review of Internet-based supportive interventions for caregivers of patients with dementia.

OBJECTIVE: Because of the expected increase in the number of dementia patients, the unlikelihood of a cure in the near future, and the rising cost of care, there is an increasing need for effective caregiver interventions. Internet interventions hold considerable promise for meeting the educational and support needs of informal dementia caregivers at reduced costs. The current study aims to provide an overview of the evidence for the effectiveness, feasibility, and quality of Internet interventions for informal caregivers of people with dementia. METHODS: A systematic literature search of five scientific databases was performed, covering literature published up to 10 January 2013. Twelve studies were identified. The quality of the included studies was assessed according to the Cochrane level of evidence and the criteria list of the Cochrane Back Review Group. RESULTS: The intervention types, dosage, and duration differed widely, as did the methodological quality of the included studies. The overall level of evidence was low. However, the results demonstrate that Internet interventions for informal dementia caregivers can improve various aspects of caregiver well-being, for example, confidence, depression, and self-efficacy, provided they comprise multiple components and are tailored to the individual. Furthermore, caregivers could benefit from interaction with a coach and other caregivers. CONCLUSIONS: Internet interventions for informal dementia caregivers may improve caregiver well-being. However, the available supporting evidence lacks methodological quality. More randomized controlled studies assessing interventions performed according to protocol are needed to give stronger statements about the effects of supportive Internet interventions and their most promising elements.

[Managing concerns about falls in older people: evaluation of the implementation of an evidence-based program]. / Zicht op Evenwicht. Evaluatie van een landelijk geïmplementeerde cursus gericht op het verminderen van bezorgdheid om te vallen bij zelfstandig wonende ouderen.

INTRODUCTION: A cognitive behavioral program reduced concerns about falling and related avoidance behavior among older community-dwelling adults in a randomized controlled trial. In the current study we examined the effects and acceptability of the program after nation-wide implementation into home care organizations in The Netherlands. METHODS: In a one-group pretest-posttest study with data collection before the start of the program and at 2 and 4 months, the effects and acceptability of the program were assessed in 125 community-dwelling older people. The outcomes of the effect evaluation included concerns about falls, related avoidance behavior, falls, fall-related medical attention, feelings of anxiety, symptoms of depression, and loneliness. RESULTS: Pretest-posttest analyses with the Wilcoxon signed-rank test and the paired t-test showed significant improvements at 4 months for concerns about falls, activity avoidance, number of falls in the past 2 months, feelings of anxiety, and symptoms of depression. No significant differences were shown for the other outcomes. DISCUSSION: After implementation in home care organizations, the outcomes indicate positive program effects on concerns about falls, avoidance behavior, and falls in community-dwelling older people. Given the similarity in results, i.e. between those of the previously performed randomized controlled trial and those of the current pretest-posttest study, we conclude that the program can be successfully implemented in practice. This article is an adjusted, Dutch version of Zijlstra GA, van Haastregt JC, Du Moulin MF, de Jonge MC, van der Poel A, Kempen GI. Effects of the implementation of an evidenc-based program to manage concerns about falls in older adults. The Gerontologist 2013;53(5):839-849; doi: 10.1093/geront/gns142.

[Small-scale, homelike care environments for people with dementia: effects on residents, family caregivers and nursing staff]. / Kleinschalig wonen voor ouderen met dementie: de invloed op bewoners, mantelzorgers en medewerkers.

Institutional dementia care is increasingly directed towards small-scale and homelike care environments, in The Netherlands as well as abroad. In these facilities, a small number of residents, usually six to eight, live together, and normal daily household activities and social participation are emphasized. In a quasi-experimental study, we studied the effects of small-scale, homelike care environments on residents (n = 259), family caregivers (n = 206) and nursing staff (n = 305). We compared two types of institutional nursing care during a 1 year period (baseline assessment and follow-up measurements at 6 and 12 months): (28) small-scale, homelike care environments and (21) psychogeriatric wards in traditional nursing homes. A matching procedure was applied to increase comparability of residents at baseline regarding functional status and cognition. This study was unable to demonstrate convincing overall effects of small-scale, homelike care facilities. On our primary outcome measures, such as quality of life and behaviour of residents and job satisfaction and motivation of nursing staff, no differences were found with traditional nursing homes. We conclude that small-scale, homelike care environments are not necessarily a better care environment than regular nursing homes and other types of living arrangements should be considered carefully. This provides opportunities for residents and their family caregivers to make a choice which care facility suits their wishes and beliefs best.

Cognitive hostility predicts all-cause mortality irrespective of behavioural risk at late middle and older age.

BACKGROUND: Most but not all evidence supports hostility-related attributes to increase mortality risk. However, studies usually include single attributes, their effects have been studied predominantly in younger populations, and behavioural pathways explaining the mortality effect seem to differ by age. We examined the relationship between all-cause mortality and cognitive hostility, anger, aggression and rebelliousness, and their independence of health behaviours in a late middle-aged and older population. METHODS: Data were derived from the longitudinal Dutch Study of Medical Information and Lifestyles in the city of Eindhoven, in the Southeast of the Netherlands study among 2679 late middle-aged and older Dutch people. Psychological characteristics were self-reported in 2004/2005, and mortality was monitored from 2005 to 2010. Cox regression analyses were used to calculate the mortality risk by each unique psychological variable with additional adjustments for the other psychological variables and for health behaviours. Baseline adjustments included age, sex, educational level and prevalent morbidity. RESULTS: Cognitive hostility was associated with all-cause mortality, independent of health behaviours (on a scale ranging from 6 to 30, the hazard ratio (HR) was 1.05; 95% confidence interval [95% CI): 1.01-1.09]. Anger, aggression and rebelliousness were not associated with mortality risk. CONCLUSIONS: In diminishing excess mortality risks, hostile cognitions might be acknowledged separately and additionally to the risk posed by unhealthy lifestyles.

["A matter of balance--Netherlands": an effective intervention to reduce concerns about falls and related avoidance of activity in older people]. / 'Zicht op Evenwicht': een effectieve interventie om bezorgdheid om te vallen en gerelateerd vermijdingsgedrag bij ouderen te verminderen.

Concerns about falls and related avoidance behavior are common among older people and may lead to decreased quality of life, decreased physical and psychosocial functioning, and premature admission to a nursing home. In a randomized controlled trial among 540 community-dwelling older people we studied the feasibility and effects of a cognitive behavioral program on concerns about falls, related avoidance of activity, and falls. Data of the process evaluation obtained from participants in the intervention group (n = 280) and the trainers (n = 6) showed that the program was considered as feasible by the trainers, and positively judged by participants and trainers. Furthermore, participants experienced benefits from attending the program (61% still reported benefits one year after the program). Prior to the start of the program 26% of the participants of the intervention dropped out, yet, among the participants who started the program completion was high (84%). The effect evaluation showed positive outcomes for concerns about falls, related avoidance of activity, and daily activity at 2 months (after the program) when comparing the intervention group with the control group (n = 260). Long-term effects were also shown for, amongst others, concerns about falls and recurrent falls. Following these positive results the cognitive behavioral group program is currently made available to geriatric care settings nationwide in the Netherlands.

[The psychometric properties of three self-report screening instruments for identifying frail older people in the community]. / Psychometrische eigenschappen van drie screeningsinstrumenten voor kwetsbaarheid bij thuiswonende ouderen.

BACKGROUND: Frailty can lead towards serious adverse consequences, such as disability. With regard to prevention valid screening instruments are needed to identify frail older people. The aim was to evaluate and compare the psychometric properties of three screening instruments: the Groningen Frailty Indicator (GFI), the Tilburg Frailty Indicator (TFI) and the Sherbrooke Postal Questionnaire (SPQ). For validation purposes the Groningen Activity Restriction Scale (GARS) was added. METHODS: A questionnaire was sent to 687 older people (> or = 70 years). (1) Agreement between instruments, (2) internal consistency, (3) cumulative scalability according to Mokken scale analysis and (4) construct validity were evaluated. RESULTS: The response rate was 77%. Prevalence estimates of frailty ranged from 40% to 59%. The highest agreement was found between the GFI and TFI (Cohen's kappa = 0.74). Cronbach's alpha for the GFI, TFI and SPQ was 0.73, 0.79 and 0.26, respectively. The scalability of the three instruments was inadequate (Loevinger's H: 0.28, 0.30 and 0.09 for GFI, TFI and SPQ, respectively). Frailty scores correlated significantly with each other and with the GARS scores. CONCLUSION: Especially the GFI and TFI seem to be useful to identify frail older people. Further research regarding their predictive validity is still needed.

Psychometric properties of the Screening Inventory of Psychosocial Problems (SIPP) in Dutch cancer patients treated with radiotherapy.

The Screening Inventory of Psychosocial Problems (SIPP) was developed to assess psychosocial distress in Dutch cancer patients. It is short, easily completed by patients and quickly interpreted by medical staff. In this study, we investigated the psychometric properties of the SIPP in 289 Dutch cancer patients treated with radiotherapy. The SIPP was administered alongside the Hospital Anxiety and Depression Scale and the Mental Adjustment to Cancer scale. In-depth structured clinical interviews were also conducted with 76 patients. Results indicate that the psychometric properties of the SIPP are promising with respect to its reliability, construct validity as evaluated with confirmatory factor analysis, and convergent and divergent validity. Receiver operating characteristics analysis showed that the SIPP successfully differentiates between patients known to have symptoms of distress and those who do not. The SIPP is therefore a reliable and valid instrument for identifying distress in cancer patients. It differs from previously developed instruments in that it measures different domains of distress in only a few minutes, and provides opportunity for patients to indicate whether they would like to discuss identified problem areas. Due to its convenient format, the SIPP may easily be used to assess psychosocial distress in cancer patients as a routine part of the clinical consultation.

The educational patterning of health-related adversities in individuals with major depression.

BACKGROUND: Major depressive disorder and depression severity are socially patterned, disfavouring individuals from lower socioeconomic groups. Depressive disorders are associated with several adverse health-related outcomes. We examined the educational patterning of somatic health, lifestyles, psychological function and treatment modalities in individuals suffering from major depressive disorder. METHODS: We used cross-sectional medical and psychiatric data from 992 participants of The Netherlands Study of Depression and Anxiety (NESDA) with a diagnosed current major depressive disorder. Associations of education with somatic, lifestyle-related, and psychological outcomes, and with treatment modalities, adjusted for depression severity, were examined by means of (multinomial and binary) logistic and linear regression analyses. RESULTS: In addition to and independent of major depressions being more severe in the less educated patients, metabolic syndrome, current smoking, low alcohol consumption, hopelessness and low control were more prevalent in a group of less educated individuals suffering from major depression, compared with their more highly educated peers. The less educated persons were more likely to be treated with antidepressant medication and less likely to receive psychotherapy treatment. None of these observations were explained by a higher depression severity in the less educated group. LIMITATIONS: The cross-sectional design does not allow us to make direct causal inferences regarding the mutual influences of the different health-related outcomes. CONCLUSIONS: Further research should explore the necessity and feasibility of routine screening for additional health risk, particularly among less educated depressed individuals.

Measuring rebelliousness and predicting health behaviour and outcomes: an investigation of the construct validity of the Social Reactivity Scale.

The Social Reactivity Scale is a questionnaire measure of individual differences in rebelliousness. The associations between rebelliousness, health behaviours and health outcomes were examined in two Dutch samples by means of cross-sectional survey data. We found moderate support for the reliability and construct validity of the scale. Findings were suggestive of rebelliousness, first, being associated with low control beliefs, second, being related to hostility and, third, also heightening the risk of engaging in unhealthy behaviours and that of poor health (perhaps through deliberately rejecting health education messages). Findings thus contribute to the ongoing emergence of an empirically viable theoretical construct.

Effects and feasibility of a standardised orientation and mobility training in using an identification cane for older adults with low vision: design of a randomised controlled trial.

BACKGROUND: Orientation and mobility training (O&M-training) in using an identification cane, also called symbol cane, is provided to people with low vision to facilitate independent participation in the community. In The Netherlands this training is mainly practice-based because a standardised and validly evaluated O&M-training in using the identification cane is lacking. Recently a standardised O&M-training in using the identification cane was developed. This training consists of two face-to-face sessions and one telephone session during which, in addition to usual care, the client's needs regarding mobility are prioritised, and cognitive restructuring techniques, action planning and contracting are applied to facilitate the use of the cane. This paper presents the design of a randomised controlled trial aimed to evaluate this standardised O&M-training in using the identification cane in older adults with low vision. METHODS/DESIGN: A parallel group randomised controlled trial was designed to compare the standardised O&M-training with usual care, i.e. the O&M-training commonly provided by the mobility trainer. Community-dwelling older people who ask for support at a rehabilitation centre for people with visual impairment and who are likely to receive an O&M-training in using the identification cane are included in the trial (N = 190). The primary outcomes of the effect evaluation are ADL self care and visual functioning with respect to distance activities and mobility. Secondary outcomes include quality of life, feelings of anxiety, symptoms of depression, fear of falling, and falls history. Data for the effect evaluation are collected by means of telephone interviews at baseline, and at 5 and 17 weeks after the start of the O&M-training. In addition to an effect evaluation, a process evaluation to study the feasibility of the O&M-training is carried out. DISCUSSION: The screening procedure for eligible participants started in November 2007 and will continue until October 2009. Preliminary findings regarding the evaluation are expected in the course of 2010. If the standardised O&M-training is more effective than the current O&M-training or, in case of equal effectiveness, is considered more feasible, the training will be embedded in the Dutch national instruction for mobility trainers. TRIAL REGISTRATION: ClinicalTrials.gov NCT00946062.

Personality and health as predictors of income decrease in old age: findings from the longitudinal SMILE study.

BACKGROUND: There is much evidence for the influence of low socio-economic status on poor health. It is, however, also important to study the ways in which people attain and retain their socio-economic status and the factors that predict changes in socio-economic status, such as a decrease in income. Such mobility also occurs in older populations, in which financial and health-related changes are very common, especially after retirement. METHODS: Three years of follow-up data from 1443 Dutch men and women aged 55 years and older who participated in the Study on Medical Information and Lifestyles Eindhoven (SMILE) were gathered. Logistic regression analyses were used to study the independent effects of physical and mental dysfunction and severity of chronic diseases and adverse personality factors on decrease in income. RESULTS: Social anxiety (OR = 1.62, 95% CI: 1.09-2.40), physical dysfunction (OR = 1.71, 95% CI: 1.07-2.74) and severe diseases (OR = 1.37, 95% CI: 1.05-1.78) were significant predictors of decrease in income. These contributions were independent of each other, and remained robust after controlling for other confounding factors, such as gender, age and educational level and change in employment status. Mental dysfunction and other personality characteristics, such as hostility and mastery, did not contribute to decrease in income. CONCLUSION: Social anxiety and poor physical health are relevant factors associated with decrease in income in old age. The findings suggest that these factors are important in retaining one's socio-economic status. Future longitudinal research is necessary to further disentangle the mechanisms and pathways related to socio-economic health inequalities along the life-course.

[Psychosocial aspects of health and functioning in old age: from determinants towards intervention]. / Psychosociale aspecten van gezondheid en zelfredzaamheid bij ouderen: van determinanten naar interventie.

A central issue within the area of social gerontology refers to the explanation why some older people--despite medical problems--function quite well at an older age while others do not. This paper describes a conceptual approach that enables us to understand individual differences in daily functioning in the chronically ill, thus providing a starting point for the development of interventions to improve daily functioning in old age. More specifically, the role of self-efficacy expectancies and perceived control in daily functioning of older persons are elaborated. The presented studies show that both concepts are not predominant but contribute in a consistent way to old people's daily functioning. This knowledge has resulted in the development and evaluation of psychosocial interventions to improve functioning and to reduce disability. Two examples of such interventions are described: the reduction of fear of falling and self-management of patients with congestive heart failure. The development and evidence of interventions to improve daily functioning in old age are still in their infancy but are promising. The encouragement of the further development of such interventions may help to improve health care for older people as they may fit within the perspective of older people themselves and may reduce the need of care.