Interprofessional collaboration in palliative dementia care.

Interprofessional collaboration (IPC) is essential for high-quality palliative care (PC) for persons with dementia. The aim of this scoping review was to identify IPC approaches in palliative dementia care and explore the elements constituting these approaches. We performed a search in PubMed, CINAHL, and PsychINFO using the Joanna Briggs Institute Reviewers' manual and PRISMA guidelines, and conducted content analysis of the included articles. In total, 28 articles were included, which described 16 IPC approaches in palliative dementia care. The content analysis revealed three overall elements of these approaches: 1) collaborative themes, 2) collaborative processes, and 3) resources facilitating collaboration. Frequently reported collaborative themes embraced pain management and providing care in the dying phase. These themes were addressed through intertwined collaborative processes including communication, coordination, assessing and monitoring, and reflecting and evaluating. To ensure optimal IPC in palliative dementia care, various resources were required, such as PC knowledge, skills to manage symptoms, skills to communicate with collaborators, and a facilitating environment. In conclusion, the identified IPC approaches in palliative dementia care involve diverse collaborating professionals who mainly manage symptoms, prepare for the dying phase and require material and immaterial resources to enable optimal IPC in palliative dementia care.

Nurses' needs when collaborating with other healthcare professionals in palliative dementia care.

Adequate interprofessional collaboration is essential to provide high quality palliative dementia care across different settings. Within interprofessional collaboration, nurses are the frontline healthcare professionals (HCPs), who interact closely with people with dementia, their loved ones, and other HCPs. A survey was conducted to explore the needs of nurses regarding interprofessional collaboration in home care (HC) organisations, nursing homes (NHs) and during NH admissions. The survey identified the perceived quality of and preferred needs regarding interprofessional collaboration. In total, 384 participants (53.9% home care nurses) completed the survey. The most frequently reported collaboration needs in HC organisations and NH were optimal communication content e.g. information transfer and short communication lines (being able to easily contact other disciplines), and coordination e.g. one contact person, and clear task division and responsibilities). During NH admissions, it was important to create transparency about agreements concerning end-of-life wishes, optimize nurse-to-nurse handover during NH admissions (through performing visits prior to admissions, and receiving practical information on how to guide relatives), and improve coordination (e.g. one contact person). In conclusion, the key collaboration needs were organising central coordination, establishing optimal communication, and creating transparency on end-of-life care agreements.

Sarcopenia Is Related to Mortality in the Acutely Hospitalized Geriatric Patient.

BACKGROUND: Sarcopenia is defined as low skeletal muscle mass with poor physical performance, representing a strong prognostic factor for mortality in older people. Although highly prevalent in hospitalized geriatric patients, it is unknown whether sarcopenia can also predict mortality in these patients. OBJECTIVE: To determine the association between sarcopenia according the criteria of the European Working Group on Sarcopenia in Older People (EWGSOP), International Working Group on Sarcopenia (IWGS), Special Interest Group of Sarcopenia, Cachexia and Wasting Disorders (SIG) and Foundation for the National Institutes of Health (FNIH) and 2-year mortality in acutely hospitalized geriatric patients. DESIGN: 81 patients (84±5 y) admitted to the acute geriatric ward participated in this study. Body composition assessment (bio-impedance, Maltron Bioscan 920-II) and physical performance tests were performed, and mortality information was retrieved through patient files. RESULTS: Prevalence rates of sarcopenia were 51% (EWGSOP), 75% (IWGS), 69% (SIG), and 27% (FNIH). Based on Cox proportional hazard ratio (HR) analysis, 2-year mortality was significantly higher in sarcopenic patients versus non-sarcopenic patients when using the EWGSOP (2-y: HR 4.310; CI-95%:2.092-8.850; P<0.001) and FNIH criteria (2-y: HR 3.571; CI-95%:1.901-6.711; P<0.001). Skeletal muscle mass index, fat mass index, body mass index, phase angle and gait speed were significantly lower in the geriatric patients who deceased after 2 years versus those who were still alive. Cox proportional HR analyses showed that higher phase angle (HR 0.678; CI-95%:0.531- 0.864; P=0.002) and higher fat mass index (HR 0.839; CI-95%:0.758-0.928; P=0.001) significantly reduced 2-y mortality probability. Combining sarcopenia criteria and separate patient characteristics finally resulted in a model in which HRs for sarcopenia (EWGSOP and FNIH) as well as phase angle significantly predicted mortality probability. CONCLUSION: Sarcopenia is prevalent in acutely hospitalized geriatric patients and is associated with significantly higher 2-year mortality according the EWGSOP and FNIH criteria.

International Clinical Practice Guidelines for Sarcopenia (ICFSR): Screening, Diagnosis and Management.

OBJECTIVES: Sarcopenia, defined as an age-associated loss of skeletal muscle function and muscle mass, occurs in approximately 6 - 22 % of older adults. This paper presents evidence-based clinical practice guidelines for screening, diagnosis and management of sarcopenia from the task force of the International Conference on Sarcopenia and Frailty Research (ICSFR). METHODS: To develop the guidelines, we drew upon the best available evidence from two systematic reviews paired with consensus statements by international working groups on sarcopenia. Eight topics were selected for the recommendations: (i) defining sarcopenia; (ii) screening and diagnosis; (iii) physical activity prescription; (iv) protein supplementation; (v) vitamin D supplementation; (vi) anabolic hormone prescription; (vii) medications under development; and (viii) research. The ICSFR task force evaluated the evidence behind each topic including the quality of evidence, the benefit-harm balance of treatment, patient preferences/values, and cost-effectiveness. Recommendations were graded as either strong or conditional (weak) as per the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Consensus was achieved via one face-to-face workshop and a modified Delphi process. RECOMMENDATIONS: We make a conditional recommendation for the use of an internationally accepted measurement tool for the diagnosis of sarcopenia including the EWGSOP and FNIH definitions, and advocate for rapid screening using gait speed or the SARC-F. To treat sarcopenia, we strongly recommend the prescription of resistance-based physical activity, and conditionally recommend protein supplementation/a protein-rich diet. No recommendation is given for Vitamin D supplementation or for anabolic hormone prescription. There is a lack of robust evidence to assess the strength of other treatment options.

Usually Available Clinical and Laboratory Data Are Insufficient for a Valid Medication Review: A Crossover Study.

OBJECTIVES: To establish the quality of medication reviews performed by nursing home physicians, general practitioners and pharmacists. DESIGN AND SETTING: 15 Pharmacists, 13 general practitioners and 18 nursing home physicians performed a medication review for three cases (A, B and C), at three evaluation moments. First, they received the medication list. Secondly, they also received laboratory results and reason for admission and finally, we added medical history. Remarks were divided into 6 categories, i.e. indication without medication, medication without indication, contraindications/ interactions, dosage problems, double medication and wrong medication. Remarks were compared to the remarks made by our expert panel and scored according to our grading model as appropriate (0 to +3) or missed or potentially harmful (-1). For each medication error category, the percentage of participants who made this error was computed. RESULTS: After the first evaluation moment, the overall estimated mean percentage score was -1.7% for case A, 3.9% for case B, and 8.7% for case C. After the second review, this score was 15.0% for case A, 19.8% for case B, and 22.2% for case C. This further increased to 30.0% for case A, 36.7% for case B and 44% for case C at the final evaluation. The absence of medication where there was an indication (indication without medication) was frequently missed and did not improve after adding the extra information regarding laboratory results, reason for admission and finally medical history. CONCLUSION: Increasing clinical information helps physicians and pharmacists to improve their medication reviews, however, additional information was still related with a high margin of error. Detection of certain errors becomes easier with additional information, whereas other errors remain undetected. To achieve a high standard of medication review, we have to change the way medication reviews should be performed.

Impact of Different Diagnostic Criteria on the Prevalence of Sarcopenia in an Acute Care Geriatric Ward.

BACKGROUND: Sarcopenia is probably an important causal factor for functional decline in acutely ill hospitalized geriatric patients. Low skeletal muscle mass, low gait speed and low grip strength are hallmarks of diagnosing sarcopenia. However there are many different diagnostic criteria to assess sarcopenia. OBJECTIVES: In this study the influence of different criteria for sarcopenia was studied on sarcopenia prevalence in geriatric patients admitted to an acute care hospital. DESIGN: Cross sectional study design. SETTING: A geriatric ward of a large Dutch hospital. PARTICIPANTS: Geriatric patients. MEASUREMENTS: Skeletal muscle mass measured using bio impedance analysis (BIA), gait speed using the 4 meter walking test and grip strength. The sarcopenia prevalence was investigated according to criteria of: muscle mass, grip strength, the European Working Group on Sarcopenia in Elderly People, the International Working Group on Sarcopenia and the Special Interest Group of Society of Sarcopenia, Cachexia and Wasting Disorders. RESULTS: 85 geriatric patients were included (61 women). Applying the 17 different criteria, the sarcopenia prevalence varied from 26-75% for women and from 42-100% for men. Comparing the Janssen calculation with the Maltron calculation sarcopenia prevalence ranged from respectively 26-67% and 67-70% for women and from 42-71% and 75-100% for men. Almost all patients (96%) had a low gait speed. CONCLUSIONS: Sarcopenia is highly prevalent in an acute hospitalized geriatric population, although the prevalence varies widely depending on the diagnostic criteria applied. A prospective study is needed to discover which criteria of sarcopenia can predict best adverse outcomes.

[Sarcopenia]. / Sarcopenie.

Sarcopenia, the decrease in muscle mass and function, may lead to various negative health outcomes, including loss of physical performance and loss of the ability to perform the activities of daily living. The exact mechanisms of sarcopenia are not yet fully understood, but it is obvious that besides ageing, metabolic alterations, diseases, nutrition, and physical exercise play a major role. In the Netherlands, screening ofsarcopenia is not yet performed in daily practice. Evidence exists that training of muscle strength, whether or not combined with a dietary intervention, has a positive effect on the loss of muscle mass and function.

[How much do patients and health professionals (really) know? The surplus value of a home visit to the patient with polypharmacy by the practice nurse, to support medication reviews in primary care]. / Wat weten de patiënt en zijn hulpverlener: de meerwaarde van een huisbezoek door de praktijkondersteuner bij de medicatiebeoordelingen van patiënten met polyfarmacie in de eerste lijn.

BACKGROUND: Polypharmacy in older people should be addressed by an annual review of the chronic medication. In the PIL-study this was done by an integrated approach by GP, practice nurse, pharmacist, specialist and patient. All patients were first visited at home by the practice nurse. RESEARCH QUESTIONS: What 'over the counter' (OTC) medications do polypharmacy patients use? Do they know the indications of the prescribed medication? Does medication use according to the patient match with medication use according to the records of GP and pharmacist? METHOD: Inclusion criteria were: age 60 years or older, daily use of five or more chronic medications, mental competence, and adequate command of the Dutch language. All patients were visited at home by the practice nurse, who made an inventory of the actual drug use. RESULTS: Five hundred fifty patients used a total of 5576 drugs, including 527 (9.4%) OTC medication. Patients knew the indication of 64% of the prescribed medication. The number of prescribed drugs that a patient actually used did not match the numbers known to GP and pharmacist. In 60.4% of all medication prescriptions there was complete agreement between GP, pharmacist and patient. On a patient level agreement was 18.7%. CONCLUSIONS: Home visits by the nurse practitioner to make an inventory of the medication as reported by the patient seem to have an added value.

Predicting the need for end-of-life care for elderly cancer patients: findings from a Dutch regional cancer registry database.

Over 80% of all deaths in the Netherlands concern people aged 65 years and older. Elderly patients who have been diagnosed with a life-limiting illness have many unmet healthcare needs in the last phase of their life. For this exploratory population-based study, data from the Eindhoven Cancer Registry were retrospectively analysed to determine possible trends in the number, patient characteristics, treatment and survival of patients aged 65 years and older newly diagnosed with stage IV cancer (n= 9028), a group of elderly in the palliative phase of cancer. During 1996-2006 a substantial increase of 81% in the number of elderly patients newly diagnosed with cancer stage IV was found. Over 70% of these patients received primary cancer treatment, irrespective of serious comorbidity (in 61% of them) and a short life expectancy (most died within 12 months except for those with cancer of the prostate). The vast increase in the number of the elderly who need palliative care contributes to awareness among healthcare professionals about future demand. They enable anticipation and planning sufficient end-of-life care capacity, but also to develop care planning programmes for these older palliative cancer patients. Research needs to be done on aspects of the symptom burden, role of palliative treatment, psychological, social and spiritual needs and end-of-life decision-making. Registration of additional data on these aspects of (palliative) care is suggested.

Perceptions of terminally ill patients and family members regarding home and hospice as places of care at the end of life.

To enable demand-based palliative care, it is important to know the perceptions of terminally ill patients and their family members regarding home and hospice as places of care at the end of life. Eight women and five men suffering from cancer and with a life expectancy of 3 months or less were interviewed. In each case one of the family members was also interviewed. Four patients spent their last phase of life at home, nine in a hospice. This paper provides further insight in the patient perspective in palliative care. The results reveal that a cohabiting partner seems an important prerequisite for terminally ill patients to stay at home. For spouses it is an obvious choice to facilitate the patients' stay at home, even when it becomes too demanding, something not discussed between spouse and patient. When sufficient care at home seems impossible and the negotiation between patients and family members results in the opinion that living at home is no longer an option, it is decided that the patient moves to a hospice. The choice for the specific setting of the patients' new residence seems to be random; one possibility is pointed out to them and seems appropriate.

The SNAQ(RC), an easy traffic light system as a first step in the recognition of undernutrition in residential care.

OBJECTIVE: Development and validation of a quick and easy screening tool for the early detection of undernourished residents in nursing homes and residential homes. DESIGN: Multi-center, cross sectional observational study. SETTING: Nursing homes and residential homes. PARTICIPANTS: The screening tool was developed in a total of 308 residents (development sample; sample A) and cross validated in a new sample of 720 residents (validation sample) consisting of 476 nursing home residents (Sample B1) and 244 residential home residents (sample B2). MEASUREMENTS: Patients were defined severely undernourished when they met at least one of the following criteria: BMI or= 5% unintentional weight loss in the past month and/or >or= 10% unintentional weight loss in the past 6 months. Patients were defined as moderately undernourished if they met the following criteria: BMI 20.1-22 kg/m2 and/or 5-10% unintentional weight loss in the past six months. The most predictive questions (originally derived from previously developed screening instruments) of undernourishment were selected in sample A and cross validated in sample B. In a second stage BMI was added to the SNAQRC in sample B. The diagnostic accuracy of the screening tool in the development and validation samples was expressed in sensitivity, specificity, and the negative and positive predictive value. RESULTS: The four most predictive questions for undernutrition related to: unintentional weight loss more than 6 kg during the past 6 months and more than 3 kg in the past month, capability of eating and drinking with help, and decreased appetite during the past month. The diagnostic accuracy of these questions alone was insufficient (Se=45%, Sp=87%, PPV=50% and NPV=84%). However, combining the questions with measured BMI sufficiently improved the diagnostic accuracy (Se=87%, Sp=82%, PPV=59% and NPV=95%). CONCLUSION: Early detection of undernourished nursing- and residential home residents is possible using four screening questions and measured BMI.

Preventing and treating dehydration in the elderly during periods of illness and warm weather.

OBJECTIVE: Translate the available knowledge on ageing and dehydration into main messages for clinical practice. MAIN POINTS: Older people are more susceptible to dehydration than younger people. This is partly due to lack of thirst sensation and changes in the water and sodium balance that naturally occur as people age. It is also, to some degree, attributable to the fact that elderly people, both those living at home and those living in institutions, often have various impairments, disabilities and/or handicaps (comorbidity). They also tend to use numerous drugs and medication for these illnesses (polypharmacy). Multimorbidity and polypharmacy often overstress the normal age-related physiological changes in the water and sodium balance and therefore increase elderly people's risk of dehydration,especially during intercurrent infections or warm weather. Elderly people, whether they are living on their own or in an institution, and especially elderly people that can no longer take care of themselves because of cognitive, sensory, motor and/or ADL impairments, need extra help to stay hydrated. The most important strategy is simply a matter of ensuring that elderly people consume a sufficient amount of fluids (at least 1.7 liters every 24 hours). Additional strategies include making healthy drinks and water easily available and accessible at all times and reminding and encouraging the elderly to consume these fluids. Elderly people should not be encouraged to consume large amounts of fluids at once but rather small amounts throughout the day. When the recommended fluid intake cannot, for whatever reason, be realized, fluids can be administered via catheter or by hypodermoclysis. In more specific and severe cases, fluids can be administered intravenously. CONCLUSION: The prevention, signaling and treatment of dehydration in the elderly is an important multidisciplinary endeavor. Formal and informal care providers need to continuously be aware of the risk factors and signs of dehydration in the elderly, especially during periods of very warm weather and when older people are ill. Standard professional care for high risk patients is imperative.

Daily symptom burden in end-stage chronic organ failure: a systematic review.

Chronic diseases are nowadays the major cause of morbidity and mortality worldwide. Patients with end-stage chronic organ failure may suffer daily from distressful physical and psychological symptoms. The objective of the present study is to systematically review studies that examined daily symptom prevalence in patients with end-stage chronic organ failure, with attention to those that included patients with either congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) or chronic renal failure (CRF). Thirty-nine articles (8 CHF, 7 COPD, 2 CHF and COPD, 22 CRF) have been included. The included studies used various study designs. There was a wide range of daily symptom prevalence that may be due to the heterogeneity in methodology used. Nevertheless, findings suggest significant symptom burden in these patients. This review highlights the need for further prospective and longitudinal research on symptom prevalence in patients with end-stage CHF, COPD and CRF to facilitate the development of patient-centred palliative care programs.