Value reorientation and intergenerational conflicts in ageing societies.

The Ageing of societies is a unique historical development of mankind. Today, such ageing is recognized as a threat for developed societies. There is fear of increasing inequality in health and in access to health care. Apart from the costs of ageing and care, such fear creates intergenerational conflicts. This paper explores what values are at stake when a society ages. At issue here is the social position of the old citizens and the way in which they are regarded by their fellow citizens. Findings indicate the need to contemplate the consequences of ageing for societies and to discuss the impact these have for the values dominating contemporary post-welfare states. European welfare states were based on a balanced combination of three values: freedom, equality, and solidarity. Because these values are misbalanced now, equal accessibility of care and conditions for social participation are disappearing. Therefore, we shall have to think about new ways in which our societies can reaffirm basic human values.

Assessment of Patient Participation in Physical Rehabilitation Activities: An Integrative Review.

PURPOSE: In addition to the amount and intensity of rehabilitation interventions and the number of therapies, the degree of patient participation in physical rehabilitation activities is key. For this reason, adequate information regarding participation is necessary to evaluate patient performance. This article reviews instruments designed to assess participation in physical rehabilitation activities. DESIGN: Integrative review. METHODS: Pubmed, CINAHL, PsycInfo, Embase, and Cochrane Library database were searched for publications between January 1976 and July 2012. Secondary searches were also conducted and reference lists scanned for relevant publications. FINDINGS: Fourteen articles reporting on three instruments were found. They differ with regard to their underlying theoretical concepts. Each instrument was tested in medical inpatient rehabilitation settings. CONCLUSIONS/CLINICAL RELEVANCE: Each instrument appears to be useful for assessing specific aspects of patient participation in rehabilitation activities. More theoretical work is needed to clarify the underlying concepts as these instruments are not yet ready for clinical application.

Long-term health and work outcomes of renal transplantation and patterns of work status during the end-stage renal disease trajectory.

INTRODUCTION: The aim of this study was to examine the health- and work outcomes of renal transplant recipients long-term after transplantation as well as the pattern of work status, work ability and disability benefits during the end-stage renal disease (ESRD) trajectory that precedes transplantation. METHODS: 34 transplant recipients completed interviews 3, 13 months and >6 years posttransplantation. Health status (SF-36), work ability (WAI), and fatigue (CIS) were assessed by questionnaires, clinical data were derived from medical charts, and data on functional limitations were extracted from the social security system database. The work status trajectory preceding transplantation was examined retrospectively. RESULTS: Of the 34 third wave transplant recipients, 29% were severely fatigued. Compared with the general working population, recipients experienced worse general health and less vitality. Non-working recipients had worse renal function and general health, and more limitations in physical functioning compared to working recipients. The WAI score indicated moderate work ability for 60% of the employed recipients. Although 67% were employed (45% parttime), 30% of those working still received some disability benefits. Social insurance physicians found variable levels of functional limitations. The mean work status trajectory showed more sickness absence and less work ability during dialysis, but after transplantation, both work status and work ability generally improved. CONCLUSIONS: Transplant recipients have a compromised health status which leads to functional limitations and disability. Although work status improved after transplantation, a substantial number of the transplant recipients received disability benefits. The negative health consequences of anti-rejection medications may play an important role in long-term work ability. These results indicate that a 'new' kidney has advantages over dialysis with respect to work, but does not necessarily leads to 'normal' work outcomes.

Differences in perceived health status between kidney transplant recipients and dialyzed patients are based mainly on the selection process.

Kidney transplantation offers longer survival, less morbidity and lower costs than dialysis. It is also believed to improve quality of life. The aim of this study was to compare prospectively the perceived health status (PHS) of dialyzed patients on a waiting list with kidney transplant recipients after transplantation, matched for age, gender and comorbidity. The sample consisted of 93 dialyzed patients on a waiting list for deceased-donor kidney transplantation and 87 incident transplant recipients. A total of 62 dialyzed patients were matched for age, gender and comorbidity with 62 transplant recipients. PHS was measured using the SF-36 questionnaire. Data from baseline and after 12 months were compared between the groups. Patients on dialysis had worse physical (49 +/- 21) and mental (59 +/- 18) PHS than transplant recipients (56 +/- 21 and 64 +/- 18, p < or = 0.05), but when matched pairs were compared, no differences in PHS were found. After 12 months, PHS did not change significantly in either group. The PHS of patients after kidney transplantation is better than that of those on dialysis. However, this fact is significantly influenced by the selection procedure, as only some dialyzed patients are put onto the waiting list while others were actually transplanted. The differences disappear with matching.

The psychometric properties of three self-report screening instruments for identifying frail older people in the community.

BACKGROUND: Frailty is highly prevalent in older people. Its serious adverse consequences, such as disability, are considered to be a public health problem. Therefore, disability prevention in community-dwelling frail older people is considered to be a priority for research and clinical practice in geriatric care. With regard to disability prevention, valid screening instruments are needed to identify frail older people in time. The aim of this study 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 community-dwelling older people (> or = 70 years). Agreement between instruments, internal consistency, and construct validity of instruments were evaluated and compared. RESULTS: The response rate was 77%. Prevalence estimates of frailty ranged from 40% to 59%. The highest agreement was found between the GFI and the TFI (Cohen's kappa = 0.74). Cronbach's alpha for the GFI, the TFI and the SPQ was 0.73, 0.79 and 0.26, respectively. Scores on the three instruments correlated significantly with each other (GFI - TFI, r = 0.87; GFI - SPQ, r = 0.47; TFI - SPQ, r = 0.42) and with the GARS (GFI - GARS, r = 0.57; TFI - GARS, r = 0.61; SPQ - GARS, r = 0.46). The GFI and the TFI scores were, as expected, significantly related to age, sex, education and income. CONCLUSIONS: The GFI and the TFI showed high internal consistency and construct validity in contrast to the SPQ. Based on these findings it is not yet possible to conclude whether the GFI or the TFI should be preferred; data on the predictive values of both instruments are needed. The SPQ seems less appropriate for postal screening of frailty among community-dwelling older people.

A multifactorial intervention for the prevention of falls in psychogeriatric nursing home patients, a randomised controlled trial (RCT).

OBJECTIVE: to evaluate the effectiveness of a multifactorial intervention on incidence of falls in psychogeriatric nursing home patients. DESIGN: cluster-randomised controlled 12-month trial. SETTING: psychogeriatric wards in 12 nursing homes in The Netherlands. PARTICIPANTS: psychogeriatric nursing home patients (n = 518). INTERVENTION: a general medical assessment and an additional specific fall risk evaluation tool, applied by a multidisciplinary fall prevention team, resulting in general and individual fall prevention activities. MEASUREMENTS: falls. RESULTS: there were 355 falls in 169.5 patient-years (2.09 falls per patient per year) in the intervention group and 422 falls in 166.3 patient-years (2.54 falls per patient per year) in the control group. Intention-to-treat analysis with adjustment for ward-related and patient-related parameters, and intra-cluster correlation, showed that the intervention group had a significantly lower mean fall incidence rate than the control group (rate ratio = 0.64, 95% CI = 0.43-0.96, P = 0.029). Subgroup analyses showed that fall risk declined further as patients participated longer in the intervention programme. CONCLUSION: the introduction of a structured multifactorial intervention to prevent falls in psychogeriatric nursing home patients significantly reduces the number of falls. This reduction is substantial and of high clinical relevance.

Facilitating the participation of people with aphasia in research: a description of strategies.

BACKGROUND: People with aphasia are often excluded from research because of their communication impairments, especially when an investigation into the communication impairment is not the primary goal. In our research concerning social participation of people with aphasia, we wanted to include people with mild, moderate as well as severe aphasia. AIM: To suggest strategies and techniques for research in people with aphasia based upon experiences in conducting research in this group of people. METHODS: We conducted a qualitative study and a quantitative study in people with aphasia concerning their social participation. In these studies different strategies were developed based upon the literature, conversations with people with aphasia and speech and language therapists, to facilitate the inclusion of people with aphasia, even those with severe communication problems. Several strategies were evaluated. The strategies used and our experiences are outlined in this report. MAIN CONTRIBUTION: It is possible to conduct research in this group. Several strategies were helpful to make this mission possible: the use of pre-structured diaries, the use of in-depth interviews with attention to non-verbal communication, the use of existing measurements, adjusted for people with aphasia by: using pictograms, placing one question per page, bolding the key concepts in the question, using large font, visualizing the answering possibilities in words and in pictures, reducing the question length, and excluding negatives in the question. CONCLUSION: Research in people with aphasia is possible when using strategies adjusted to the communicative impairment.

No difference between postural exercises and strength and fitness exercises for early, non-specific, work-related upper limb disorders in visual display unit workers: a randomised trial.

QUESTION: Are postural exercises delivered by Mensendieck/Cesar therapists more effective in decreasing pain, reducing disability and improving health-related quality of life in visual display unit workers with early non-specific work-related upper limb disorders than strength and fitness exercises delivered by physiotherapists? DESIGN: Randomised trial with concealed allocation and intention-to-treat analysis. PARTICIPANTS: Eighty-eight (6 drop-outs) visual display unit workers with early non-specific work-related upper limb disorders. INTERVENTION: One group received 10 weeks of postural exercises while the other group received 10 weeks of strength and fitness exercises. OUTCOME MEASURES: Pain was measured with a 10-cm visual analogue scale, disability was measured with the Disabilities of Arm, Shoulder and Hand questionnaire, and health-related quality of life was measured with the Short Form-36. Number of participants experiencing upper limb complaints was also collected. Outcome measures were collected at baseline and again at 3, 6, and 12 months. RESULTS: There was no significant difference in decrease in pain between the groups at 3 months (0.6 cm, 95% CI 0.0 to 1.2), 6 months (0.2, 95% CI -0.3 to 0.7), or at 12 months (0.1, 95% CI -0.6 to 0.8). Differences between the groups in upper limb complaints, disability, and health related quality of life were also small and not significant at any measurement occasion. CONCLUSION: Postural exercises did not result in a better outcome than strength and fitness exercises. However, 55% of visual display unit workers with early non-specific work-related upper limb disorders reported being free of complaints one year after both interventions were commenced. TRIAL REGISTRATION: ISRCTN15872455.

Factors determining social participation in the first year after kidney transplantation: a prospective study.

BACKGROUND: This study describes changes in social participation in the first year after kidney transplantation and examines the influence of clinical factors, health status, transplantation-related symptoms, and psychological characteristics on change in social participation. METHODS: A prospective study was performed on a cohort of primary kidney transplant recipients, transplanted between March 2002 and March 2003. Data on participation in obligatory activities (i.e., employment, education, household tasks) and leisure activities (i.e., volunteer work, assisting others, sports, clubs/associations, recreation, socializing, going out) were collected by in-home interviews (n=61) at 3 months (T1) and 1 year posttransplantation (T2). Analysis of covariance was performed. RESULTS: Data showed an increase in participation in obligatory activities and diversity of leisure participation between T1 and T2, although pre-end-stage renal disease level was not regained and differed from the general population. On T1, the majority of employed recipients were on sick leave, but returned to work on T2. Employment rate remained stable. An increase in obligatory participation was predicted by clinical factors (i.e., peritoneal dialysis, initial hospitalization), whereas change in leisure participation was related to serum albumin and cognitive capacity. No effects were found for type of donation, comorbidity, and renal function. CONCLUSIONS: We found that mainly clinical factors were associated with an increase in participation in society. Although health-status related factors and the psychological attribute self-efficacy may be related to recovery of social participation, their effect was outweighed by the strength of clinical predictors in multivariate analysis.

Changes in symptoms and pain intensity of cancer patients after enrollment in palliative care at home.

This study describes the activities and interventions carried out by an at-home palliative care team treating cancer patients who died within two years of being enrolled in a palliative care program. It analyzes which changes in symptoms and pain occurred and which sociodemographic and medical characteristics were related to these changes. The analysis is based on 102 cancer patients. Data were collected through systematic registration during the palliative care process. At enrollment, patients were interviewed by the coordinating general practitioner concerning their sociodemographic background, medical history, psychological status, and symptoms. During the palliative care process, symptoms and functioning of the patients were recorded by the physician and nurses. The results show that cancer patients enrolled in palliative care at home have many symptoms, often associated with metastatic disease and comorbidities. The palliative care teams delivered frequent and various interventions. The number of symptoms decreased considerably, as did pain intensity and the intensity of other symptoms. Patients living in urban areas and with low income particularly benefited from a reduction in the number of symptoms they displayed. Cancer patients who needed palliative care benefited significantly from this at-home palliative care service.

Rehabilitation in acute stroke patients in German-speaking Switzerland.

PRINCIPLES: The aim of this study was to obtain an overview of stroke-specialised rehabilitation facilities in German-speaking Switzerland, as well as the numbers of stroke patients treated. It also focused on the mode of goal-setting and evaluation, and the use of instruments to assess the patient's state and progress. METHOD: Out of 28 stroke rehabilitation facilities, 21 participated in a structured telephone interview. Of these, 18 institutions provided full data. RESULTS: The results show that the facilities (n = 18) vary considerably in numbers of patients treated per year (Ø 124, range 7-500) and length of stay (Ø 40 +/- 17.23). Goal-setting and evaluation, including the setting of short term and long term goals, is a common feature. They differ, however, in terms of patient involvement, processes and professions participating in goal-setting and evaluation. A variety of instruments are used for patient assessment at admission and during rehabilitation. Admission to rehabilitation does not rely on standardised patient health status assessment. CONCLUSIONS: Stroke rehabilitation in German-speaking Switzerland embraces a heterogeneous landscape with respect to use of instruments, goal-setting and evaluation process and patient involvement. To facilitate comparison, the same core instruments for assessment and evaluation should be selected and consistently applied. Also, the admission criterion "potential for rehabilitation" should be transformed into a universally and scientifically valid term. The effect of patient involvement in goal-setting on rehabilitation outcome has not yet been investigated. Thus no recommendations can be made for the moment.

Occurrence and measurement of transfer in cognitive rehabilitation: A critical review.

OBJECTIVE: To investigate the occurrence of transfer of cognitive strategy training for persons with acquired brain injury, and to investigate the way in which transfer is measured. METHODS: Electronic searches in PubMed, PsychINFO, EMBASE and CINAHL using combinations of search terms in the following categories: type of brain injury, transfer, type of disorder, type of intervention. A total of 39 papers was included in the review. The following aspects were judged: study design and participant characteristics, intervention characteristics and type of outcome measures used. RESULTS: Transfer outcome measures could be classified into 3 groups: non-trained items, standardized daily tasks and daily life. Most studies reported at least one type of transfer; however, the methodological quality of the studies was low. Cognitive strategy training in the evaluated studies focused on 7 domains of functioning: information processing, problem solving/executive functioning, memory/attention, language, neglect, apraxia and daily activities. CONCLUSION: Transfer of training effects of cognitive strategy training has been evaluated in a relatively small number of studies. Outcome measures used in these studies could be classified into 3 groups. Most studies reported the occurrence of transfer of training effects, although some serious remarks can be made concerning the methodological quality of the studies.

Social participation after successful kidney transplantation.

PURPOSE: To explore and describe the degree of social participation after kidney transplantation and to examine associated factors. METHOD: A cross-sectional study on 239 adult patients 1-7.3 years after kidney transplantation was performed via in-home interviews on participation in obligatory activities (i.e., employment, education, household tasks) and leisure activities (volunteer work, assisting others, recreation, sports, clubs/associations, socializing, going out). RESULTS: Kidney transplantation patients had a lower educational level, spent less time on obligatory activities, had part-time jobs more often, and participated less in sports compared to a control group from the general population. No difference was found in socializing, church attendance, volunteer work and going out. Multivariate regression analysis showed a negative association of age and a positive association of educational status and time since transplantation with obligatory participation. Multivariate logistic regression showed positive associations of education and time since transplantation with volunteer work; age was negatively and education positively associated with sports and going out, whereas living arrangement was also associated with going out. CONCLUSIONS: Although kidney transplantation patients participate less in employment and sports, they do participate in household tasks, volunteer work, going out, socializing and other leisure activities. Participation is associated with factors as age, educational status and time since transplantation.

How Important Are Health Care Expenditures for Life Expectancy? A Comparative, European Analysis.

OBJECTIVES: The relationship between health care expenditures and health care outcomes, such as life expectancy and mortality, is complex. Research outcomes show different and contradictory results on this relationship. How and why health care expenditures affect health outcomes is not clear. A causal link between the two is not proven. Without such knowledge, effects of increase/decrease in health care expenses on health outcomes may be overestimated/underestimated. This study analyzes the relationship between life expectancy at birth and expenditures on health care, taking into account expenditures of social production and education, as well as the quantity and quality of health care provisions and lifestyles. DESIGN: This is a cross-sectional study, analyzing national data of 31 European countries. First, the bivariate correlation between the dependent variable and independent variables are calculated and described. Next a forward linear regression analysis is applied. MEASUREMENT: The data are derived from standardized, comparative data bases as available in the Organisation for Economic Co-operation and Development and Eurostat. Health care expenditures are assessed as a percentage of the Gross Domestic Product (GDP). RESULTS: Health care expenditures are not the main determinant of life expectancy at birth, but social protection expenditures are. The regression analysis shows that in countries that spend a high percentage of their GDP on social protection, that have fewer curative beds and low infant mortality, whose citizens report fewer unmet health care needs and drink less alcohol, citizens have a significant longer life expectancy. CONCLUSION: To realize high life expectancy of citizens, policy measures have to be directed on investment in social protection expenditures, on improving quality of care, and on promoting a healthy life style.

Do Changes in Welfare and Health Policy Affect Life Satisfaction of Older Citizens in Europe?

OBJECTIVES: Ageing of societies causes serious political concerns on well-being of old citizens and care for the (frail) old. These concerns increased with the economic crisis of 2008. In European countries policy measures were taken to deal with the consequences of this crisis. This study explores the possible effects of these measures on life satisfaction of older citizens. METHODS: Life satisfaction was assessed through international surveys in 2007 and 2013 and changes in societal conditions, using eight indicators on demography, welfare, and health, are assessed in 31 European countries in 2006 and in 2014. Data are standardised and based on official, national surveys and statistics. RESULTS: The former found that U-shape relationship between age and life satisfaction disappeared after the crisis. Negative changes in social protection and care arrangements, taken after the economic crisis, are related to low life satisfaction in old citizens. CONCLUSIONS: Various societal conditions deteriorated in 2014 as compared to 2006. Policy measures, taken due to the 2008 economic crisis, have changed societal conditions and affected life satisfaction of older citizens negatively. In countries with a rudimentary structure of health and welfare provisions old citizens could not cope with the imposed policy measures.

Clinical factors influencing participation in society after successful kidney transplantation.

BACKGROUND: Little information is available on the degree of actual social functioning after successful kidney transplantation. Moreover, information on factors that influence participation in social activities is scarce. The aim of this study was to examine the influence of clinical factors on social outcome. METHODS: A retrospective study was performed on a cohort of primary kidney transplantation patients, transplanted between 1996 and 2001. Cross-sectional data on participation in obligatory activities (i.e. employment, education, household tasks), leisure activities (i.e. volunteer work, assisting others, sports, clubs/associations, recreation, socializing, going out) and change in participation were collected by in-home interviews (n=239). Multivariate regression analysis was performed. RESULTS: Thirty-six percent of the patients scored low on obligatory participation and only 52.4% was employed. Patients were actively involved in a wide range of leisure activities. Twenty-six percent participated in sports. Multivariate analysis (age-, sex-, and education-adjusted) of participation in obligatory activities showed negative associations with advanced age (P<0.01), comorbidity (previous cardiovascular events; P<0.01) and cadaveric transplantation (P<0.01). There was a positive association with time since transplantation (P<0.01). Multivariate analysis of diversity of participation in leisure activities and perceived change in participation after transplantation showed no statistically significant associations with clinical factors. CONCLUSIONS: Besides age, clinical factors such as type of donation (cadaveric versus living), comorbidity (previous cardiovascular events), and time since transplantation were associated with participation in obligatory activities such as employment, education and household tasks. Diversity of leisure activities and change in participation was not affected by clinical factors.

Predictors of perceived health status in patients after kidney transplantation.

BACKGROUND: Patients after kidney transplantation have decreased mortality, morbidity and better quality of life compared to people on dialysis. Major efforts are being directed towards research into graft and patient survival. Research into quality of life is less intensive. The aim of this study was to explore the predictors of perceived health status (PHS) in kidney transplant recipients. METHODS: Out of 218 patients after kidney transplantation 138 participated in the study. Linear regression analysis was performed to predict PHS, measured with the SF-36 questionnaire, in three age categories (<40, 40-59, >or=60 years). Independent variables included social support (measured with the Social Support List Discrepancies questionnaire), sociodemographic and medical variables, side effects and compliance. RESULTS: Predictors of better PHS in patients<40 years were better social support (P

Comparison of two recruitment strategies for patients with chronic shoulder complaints.

BACKGROUND: Recruiting adequate numbers of participants represents a major problem to the completion of randomised clinical trials in primary care. Information on different recruitment strategies applied in one trial is scarce. AIM: To evaluate the application of two recruitment strategies in one trial. DESIGN OF STUDY: The study was performed within the framework of a randomised clinical trial on the effectiveness of a behavioural treatment for patients with chronic shoulder complaints. SETTING: Thirty-two general practices in the Netherlands. METHOD: Patients recruited during a consultation with their GP for chronic shoulder complaints were compared with patients recruited by advertisement in a local newspaper as regards baseline characteristics, withdrawals (drop-outs and losses to follow-up) and post-treatment clinical outcomes. RESULTS: Patients recruited by the GPs (n = 83) were similar to those recruited by advertisement (n = 83) in terms of demographic characteristics and clinical outcome measures at baseline, but differed slightly in disease characteristics and treatment preferences. Recruitment strategy was not related to reasons for or numbers of withdrawals. Improvements on outcome measures were greater in patients recruited by the GPs, irrespective of allocated treatment. Results on the clinical effectiveness of treatments at the end of the treatment period or during follow-up were neither modified by recruitment strategy, nor by differences between the two strategy groups in patient characteristics found at baseline. CONCLUSION: Using two recruitment strategies did not influence the outcomes on clinical effectiveness in this trial.However, recruitment strategy should be considered as a putative modifying factor in the design of a study.

Implications of process evaluation for clinical effectiveness and clinical practice in a trial on chronic shoulder complaints.

OBJECTIVE: The intervention process was evaluated in a randomised clinical trial on the effectiveness of a behavioural Graded Exercise Therapy (GET) programme for patients with chronic shoulder complaints in primary care settings. This process evaluation was done for three reasons: first, to know whether the programme was performed as planned; second, to know whether or not this treatment is feasible in normal practice; third, to identify needs for improvement of the protocol to facilitate implication. METHODS: We evaluated the extent to which the programme is being applied according to protocol, patient adherence to the programme and the suitability of the programme according to patients and physiotherapists. Twenty participating physiotherapists and 87 patients allocated to GET were asked to evaluate the intervention process. Furthermore, a sample of 10 patients, taken from the total number of 87 patients allocated to GET, was invited to take part in a focus group interview at the end of the study. We evaluated the intervention process using a treatment registration form filled in by the physiotherapists during treatment, evaluation forms filled in independently by physiotherapists and patients 26 weeks after the start of the treatment period, and information gathered during the focus group interview at the end of the study. RESULTS: GET was applied according to protocol to an acceptable extent, and participating patients showed satisfactory adherence to the programme. CONCLUSIONS: Clinical effectiveness of GET in this trial is not influenced by flaws in the application of the programme or by lack of patient adherence. PRACTICE IMPLICATIONS: The programme could be improved in terms of the process of goal-setting, and the implementation of GET could be facilitated if the programme is embedded in a multidisciplinary approach in primary care.