Movement Patterns in Older Adults Recovering From Hip Fracture.

The aim of this study was to quantify physical activity and sedentary behavior in older adults recovering from hip fracture and to identify groups based on movement patterns. In this cross-sectional cohort study, older adults (≥70 years) were included 3 months after surgery for proximal femoral fracture. Patients received an accelerometer for 7 days. Demographics and outcomes related to physical function, mobility, cognitive functions, quality of life, and hip fracture were assessed. In total, 43 patients with sufficient accelerometer wear time were included. Across all groups, participants engaged in very low levels of physical activity, spending an average of 11 hr/day in prolonged sedentary behavior. Based on the extracted components from a principal component analysis, three groups with substantial differences in levels of physical activity and sedentary behavior could be distinguished.

Palliative care in advanced Huntington's disease: a scoping review.

BACKGROUND: As Huntington's disease (HD) is a progressive disease for which there is no cure yet, patients in the advanced stage of HD may benefit from palliative care. OBJECTIVE: To review the literature focusing on palliative care in advanced stage HD, and the level of evidence. METHODS: Publications between 1993 and October 29th, 2021 from 8 databases (Embase, Web of Science, Cochrane, Emcare, PsycINFO, Academic Search Premier, PMC PubMed Central and Pubmed) were included. The literature was deductively classified based on topics that are part of the definition of palliative care, or as care-related topics that emerged from the literature. Levels of evidence I (high) - V (low) were determined as defined by the Joanna Briggs Institute. RESULTS: Our search resulted in 333 articles, 38 of which were included. The literature covered four domains of palliative care: physical care, psychological care, spiritual care, and social care. Four other topics in the literature were: advance care planning, end-of-life needs assessments, pediatric HD care, and need for health care services. Most literature was underpinned by a low level of evidence, except for the topics on social care (Level III-V), advance care planning (Level II-V) and end-of-life needs assessments (Level II-III). CONCLUSIONS: To deliver adequate palliative care in advanced HD, both general and HD-specific symptoms and problems need to be addressed. As the level of evidence in existing literature is low, further research is essential to improve palliative care and to meet patient's wishes and needs.

The Perceived Impact of the Namaste Care Family Program on Nursing Home Residents with Dementia, Staff, and Family Caregivers: A Qualitative Study.

Objective(s): To examine the perspectives of staff, and family caregivers (i.e., family, friends, and volunteers) on the impact of the Namaste Care Family program on all involved. The Namaste Care Family program is a structured program for people with advanced dementia based on a palliative care approach in which family caregivers provide daily sessions together with staff with the aim to increase residents' quality of life. Methods: In this descriptive qualitative study, we interviewed 12 family caregivers, and 31 staff members from 10 nursing homes. Data was analyzed thematically. Results: A perceived impact of the program was identified for the residents, staff, and family caregivers. For residents, this included well-being, more engagement, enhanced interactions, changes in energy level, and weight gain. The impact on family caregivers included a more positive view of people with dementia, changes in family visits, mixed feelings during sessions, and mixed changes in relations with all involved. For staff, this included diverse work experiences, shift to more person-centered care (more time and attention for residents, and more awareness), and developing relationships with residents and colleagues. Conclusions: The Namaste Care Family program was valued for its observed benefits and shift towards a person-centered care culture.

Trends in quality of care and dying perceived by family caregivers of nursing home residents with dementia 2005-2019.

BACKGROUND: Dementia palliative care is increasingly subject of research and practice improvement initiatives. AIM: To assess any changes over time in the evaluation of quality of care and quality of dying with dementia by family caregivers. DESIGN: Combined analysis of eight studies with bereaved family caregivers' evaluations 2005-2019. SETTING/PARTICIPANTS: Family caregivers of nursing home residents with dementia in the Netherlands (n = 1189) completed the End-of-Life in Dementia Satisfaction With Care (EOLD-SWC; quality of care) and Comfort Assessment in Dying (EOLD-CAD, four subscales; quality of dying) instruments. Changes in scores over time were analysed using mixed models with random effects for season and facility and adjustment for demographics, prospective design and urbanised region. RESULTS: The mean total EOLD-SWC score was 33.40 (SD 5.08) and increased by 0.148 points per year (95% CI, 0.052-0.244; adjusted 0.170 points 95% CI, 0.055-0.258). The mean total EOLD-CAD score was 30.80 (SD 5.76) and, unadjusted, there was a trend of decreasing quality of dying over time of -0.175 points (95% CI, -0.291 to -0.058) per year increment. With adjustment, the trend was not significant (-0.070 EOLD-CAD total score points, 95% CI, -0.205 to 0.065) and only the EOLD-CAD subscale 'Well being' decreased. CONCLUSION: We identified divergent trends over 14 years of increased quality of care, while quality of dying did not increase and well-being in dying decreased. Further research is needed on what well-being in dying means to family. Quality improvement requires continued efforts to treat symptoms in dying with dementia.

Practitioners' perceptions of acceptability of a question prompt list about palliative care for advance care planning with people living with dementia and their family caregivers: a mixed-methods evaluation study.

OBJECTIVES: In oncology and palliative care, patient question prompt lists (QPLs) with sample questions for patient and family increased patients' involvement in decision-making and improved outcomes if physicians actively endorsed asking questions. Therefore, we aim to evaluate practitioners' perceptions of acceptability and possible use of a QPL about palliative and end-of-life care in dementia. DESIGN: Mixed-methods evaluation study of a QPL developed with family caregivers and experts comprising a survey and interviews with practitioners. SETTING: Two academic medical training centres for primary and long-term care in the Netherlands. PARTICIPANTS: Practitioners (n=66; 73% woman; mean of 21 (SD 11) years of experience) who were mostly general practitioners and elderly care physicians. OUTCOMES: The main survey outcome was acceptability measured with a 15-75 acceptability scale with ≥45 meaning 'acceptable'. RESULTS: The survey response rate was 21% (66 of 320 participated). The QPL was regarded as acceptable (mean 51, SD 10) but 64% felt it was too long. Thirty-five per cent would want training to be able to answer the questions. Those who felt unable to answer (31%) found the QPL less acceptable (mean 46 vs 54 for others; p=0.015). We identified three themes from nine interviews: (1) enhancing conversations through discussing difficult topics, (2) proactively engaging in end-of-life conversations and (3) possible implementation. CONCLUSION: Acceptability of the QPL was adequate, but physicians feeling confident to be able to address questions about end-of-life care is crucial when implementing it in practice, and may require training. To facilitate discussions of advance care planning and palliative care, families and persons with dementia should also be empowered to access the QPL themselves.

The Prognostic Value of Metabolic Profiling in Older Patients With a Proximal Femoral Fracture.

INTRODUCTION: High mortality rates of approximately 20% within 1 year after treatment are observed for patients with proximal femoral fractures. This preliminary study explores the prognostic value of a previously constructed mortality risk score based on a set of 14 metabolites for the survival and functional recovery in patients with proximal femoral fractures. MATERIALS AND METHODS: A prospective observational cohort study was conducted including patients admitted with a proximal femoral fracture. The primary outcome was patient survival, and the recovery of independence in activities of daily living was included as a secondary outcome. The mortality risk score was constructed for each patient and its prognostic value was tested for the whole population. RESULTS: Data was available form 136 patients. The mean age of all patients was 82.1 years, with a median follow-up of 6 months. Within this period, 19.0% of all patients died and 51.1% recovered to their prefracture level of independence. The mortality score was significantly associated with mortality (HR, 2.74; 95% CI, 1.61-4.66; P < 0.001), but showed only a fair prediction accuracy (AUC = 0.68) and a borderline significant comparison of the mortality score tertile groups in survival analyses (P = 0.049). No decisive associations were found in any of the analyses for the functional recovery of patients. DISCUSSION: These findings support the previously determined prognostic value of the mortality risk score. However, the independent prognostic value when adjusted for potential confounding factors is yet to be assessed. Also, a risk score constructed for this specific patient population might achieve higher accuracies for the prediction of survival and functional recovery. CONCLUSIONS: A modest prediction accuracy was observed for the mortality risk score in this population. More elaborate studies are needed to validate these findings and develop a tailored model for clinical purposes in this patient population.

Patient Characteristics and General Practitioners' Advice to Stop Statins in Oldest-Old Patients: a Survey Study Across 30 Countries.

BACKGROUND: Statins are widely used to prevent cardiovascular disease (CVD). With advancing age, the risks of statins might outweigh the potential benefits. It is unclear which factors influence general practitioners' (GPs) advice to stop statins in oldest-old patients. OBJECTIVE: To investigate the influence of a history of CVD, statin-related side effects, frailty and short life expectancy, on GPs' advice to stop statins in oldest-old patients. DESIGN: We invited GPs to participate in this case-based survey. GPs were presented with 8 case vignettes describing patients > 80 years using a statin, and asked whether they would advise stopping statin treatment. MAIN MEASURES: Cases varied in history of CVD, statin-related side effects and frailty, with and without shortened life expectancy (< 1 year) in the context of metastatic, non-curable cancer. Odds ratios adjusted for GP characteristics (ORadj) were calculated for GPs' advice to stop. KEY RESULTS: Two thousand two hundred fifty GPs from 30 countries participated (median response rate 36%). Overall, GPs advised stopping statin treatment in 46% (95%CI 45-47) of the case vignettes; with shortened life expectancy, this proportion increased to 90% (95CI% 89-90). Advice to stop was more frequent in case vignettes without CVD compared to those with CVD (ORadj 13.8, 95%CI 12.6-15.1), with side effects compared to without ORadj 1.62 (95%CI 1.5-1.7) and with frailty (ORadj 4.1, 95%CI 3.8-4.4) compared to without. Shortened life expectancy increased advice to stop (ORadj 50.7, 95%CI 45.5-56.4) and was the strongest predictor for GP advice to stop, ranging across countries from 30% (95%CI 19-42) to 98% (95% CI 96-99). CONCLUSIONS: The absence of CVD, the presence of statin-related side effects, and frailty were all independently associated with GPs' advice to stop statins in patients aged > 80 years. Overall, and within all countries, cancer-related short life expectancy was the strongest independent predictor of GPs' advice to stop statins.

Geriatric rehabilitation in older patients with cardiovascular disease: a feasibility study.

PURPOSE: Cardiac rehabilitation in older patients after hospitalization because of cardiovascular disease is recommended. However, many older patients do not receive cardiac rehabilitation in daily practice, due to lack of referral and poor adherence. This can be related to impaired clinical and functional status of these patients, who are more likely to present with frailty, frequent comorbidities, and disability. Geriatric rehabilitation might be a possible solution to reduce barriers to cardiac rehabilitation attendance. We developed and implemented an inpatient geriatric rehabilitation programme that was provided immediately after discharge from the hospital, for older patients with a significant functional decline during hospital admission because of cardiovascular disease: 'the GR-cardio programme'. The primary aim of the present study is to investigate feasibility of the GR-cardio programme. METHODS: This is a retrospective real-life feasibility study describing a consecutive series of older patients receiving the GR-cardio programme, with no control group. All patients had been hospitalized because of cardiovascular disease. Data on patient characteristics, functional status, health-related quality of life (HRQoL), readmissions, and mortality were collected from the patients file on admission, at discharge and 6 months after discharge from the GR-cardio programme. Feasibility of the programme was evaluated using the following outcomes: recruitment, resulting sample characteristics, safety, and preliminary evaluation of patients' responses to the GR-cardio programme. RESULTS: In total, 58 patients [mean age 78.8 (± 9.8) years; 43% male] were included in the study. On admission, functional status and HRQoL were severely impaired but showed clinically relevant improvements. During the programme, three patients died. Eighty-three percent of all patients were discharged back home after completing the rehabilitation programme with a mean length of 38 days. Mortality rate during follow-up was the highest in patients with heart failure (32%). CONCLUSIONS: This study indicates that geriatric rehabilitation for patients with cardiovascular disease is feasible. Furthermore, our results show that the GR-cardio programme can probably offer substantial benefits for patients in terms of improving functional status and HRQoL.

Screening for malnutrition in patients admitted to the hospital with a proximal femoral fracture.

INTRODUCTION: The prevalence of malnutrition in patients admitted with a proximal femoral fracture is considered high and the negative effects on health are well-studied. The SNAQ and the MNA-SF are two screening tools routinely used during admission of acute medical patients. The aim of this study is to compare the screening capacity of the SNAQ score and the MNA-SF, and to evaluate their predictive values for malnutrition using the ESPEN criteria. MATERIALS AND METHODS: A single-centre study with data routinely collected prospectively from the original patient records was performed in the Haaglanden Medical Centre Bronovo in the Netherlands. All patients with a proximal femoral fracture consecutively admitted between December 19th 2016 and December 21st 2017 were included. The Intraclass Correlation Coefficient was used to assess the agreement between the malnutrition screening tools and the predictive values were calculated to compare the SNAQ with the MNA-SF using the ESPEN diagnostic criteria as the reference standard. RESULTS: Data was available from 437 patients. Of all patients admitted with a proximal femoral fracture 16.9% was diagnosed as malnourished by the ESPEN criteria. When screened, 20.1% (SNAQ score) to 47.8% (MNA-SF) of all patients were classified as either at risk for malnutrition or as malnourished. A moderate agreement was found between the MNA-SF and the SNAQ (κ = 0.68). The sensitivity, specificity, PPV and NPV of the SNAQ score were 71.6%, 90.4%, 60% and 94% respectively, compared to 100%, 62.8%, 35.4% and 100% for the MNA-SF. DISCUSSION: The SNAQ has been proven to be a very specific screening tool and the positive predictive value tends to be higher than that of the MNA-SF. However, 28.4% of all malnourished patients with a proximal femoral fracture had a negative screening test when using the SNAQ score. CONCLUSIONS: No benefits were observed for the SNAQ over the MNA-SF as a screening tool for malnutrition in admitted patients with a proximal femoral fracture. Missing a significant portion of malnourished patients or those at risk and consequent under treatment of fragile older patients should be avoided. The well-validated MNA-SF seems more preferable as a screening tool for this patient population.

Effects of two feedback interventions on end-of-life outcomes in nursing home residents with dementia: A cluster-randomized controlled three-armed trial.

BACKGROUND: Despite increased attention for palliative care in dementia, recent studies found burdensome symptoms and unmet family caregiver needs in the last phase of life. Feedback is being used to improve the quality of palliative care, but we do not know how effective it is. AIM: To assess the effect of two feedback strategies on perceived quality of end-of-life care and comfort in dying nursing home residents with dementia. METHODS: In a cluster-randomized controlled trial, the End-of-Life in Dementia-Satisfaction With Care and the End-of-Life in Dementia-Comfort Assessment in Dying scales were completed by bereaved family caregivers of residents with dementia of 18 Dutch nursing homes. Two feedback strategies, generic feedback with mean End-of-Life in Dementia-scores and feedback with individual (patient-specific) End-of-Life in Dementia-scores, were compared to no feedback provided. The intervention groups discussed End-of-Life in Dementia-ratings in team meetings and formulated actions to improve care. Multi-level analyses assessed effects. RESULTS: A total of 668 families rated the End-of-Life in Dementia-instruments. Compared to no feedback, the generic strategy resulted in lower quality of end-of-life care in unadjusted ( B = -1.65, confidence interval = -3.27; -0.21) and adjusted analyses ( B = -2.41, confidence interval = -4.07; -0.76), while there was no effect on comfort. The patient-specific strategy did not affect the quality of end-of-life care, but it increased comfort in unadjusted analyses (only, B = 2.20, confidence interval = 0.15; 4.39; adjusted: B = 1.88, confidence interval = -0.34; 4.10). CONCLUSION: Neither feedback strategy improved end-of-life outcome. Perhaps, skills to translate the feedback into care improvement actions were insufficient. Feedback with favorable family ratings might even have triggered opposite effects. Trial number: NTR3942.

Prevalence of the Use of Opioids for Treatment of Pain in Persons with a Cognitive Impairment Compared with Cognitively Intact Persons: A Systematic Review.

AIM: To describe the prevalence of opioid use in persons with a cognitive impairment compared with cognitively intact persons and to explore factors associated with opioid prescription. METHOD: A search was made in PubMed (Medline), Embase, Cochrane, Central, Cinahl, PsychInfo and Web of Science and additional articles were identified by manual search of reference lists. Titles and abstracts were screened and eligible articles reviewed in full-text. A citation check was performed on the included articles for a complete search. Risk of bias of the included studies was assessed using an appropriate tool. RESULTS: The search yielded 610 unique hits and an additional 33 records were identified via reference checking. After screening, 23 studies were included. A citation tracking was performed for these 23 articles using Web of Science, which yielded an additional 421 articles for a second screening. After the second screening, 24 studies were included. Opioid use was divided into three classes: weak, strong, and weak and strong combined. In several articles there were more than one study conclusion on different opioid classes or in a different setting. Analysis was performed on the prevalence of opioid use (prescription rates) and the dosage of opioids. The 24 studies yielded a total of 35 study conclusions related to prescription rates and dosage. Of these, four showed a higher use of opioids in persons with a cognitive impairment, 14 an equal distribution, and 17 showed lower opioid use in cognitively impaired persons. CONCLUSION: This systematic review provides evidence for general undertreatment of pain with opioids in persons with a cognitive impairment.

Development of a practice guideline for optimal symptom relief for patients with pneumonia and dementia in nursing homes using a Delphi study.

OBJECTIVE: This study aimed to develop a practice guideline for a structured and consensus-based approach to relieve symptoms of pneumonia in patients with dementia in nursing homes. METHODS: A five-round Delphi study involving a panel consisting of 24 experts was conducted. An initial version of the practice guideline was developed with leading representatives of Dutch University Medical Centers with a department for elderly care medicine, based on existing guidelines for palliative care. The experts evaluated the initial version, after which we identified topics that reflected the main divergences. The experts rated their agreement with statements that addressed the main divergences on a 5-point Likert scale. Consensus was determined according to pre-defined criteria. The practice guideline was then revised according to the final decisions made by the project group and the representatives. RESULTS: The response rate for the expert panel was 67%. Main divergences included the applicability of guidelines for palliative care to patients with dementia and pneumonia in long-term care and the appropriateness of specific pharmacological treatment of dyspnea and coughing. Moderate consensus was reached for 80% of the statements. Major revisions included adding pharmacological treatment for coughing and recommending opioid rotation in the case of opioid-induced delirium. Two areas of divergent opinion remained: the usefulness of oxygen administration and treatment of rattling breath. The project group made the final decision in these areas. CONCLUSIONS: We developed a mostly consensus-based practice guideline for patients with dementia and pneumonia and mapped controversial issues for future investigation.

A postal screener for pain and need for treatment in older persons in primary care.

OBJECTIVES: To test the Pain intensity, Enjoyment in life, General activity questionnaire (PEG) as a postal screener for pain in older persons. DESIGN: Population-based survey. Postal screening questionnaires followed by an interview of a sample of participants. SETTING: Family practices. PARTICIPANTS: Persons aged 75 and older (N = 243; 95 interviewed). MEASUREMENTS: Screening included the PEG, a three-item abbreviated version of the Brief Pain Inventory (BPI), plus an additional question on treatment need. Pain severity and related interference was assessed (BPI) during the interview, as was the current (need for) pain treatment. RESULTS: The median PEG score of the 243 persons participating in the screening (response 76%) was 2.0 (interquartile range 0-4.7). Seventy-nine (35%) had moderate to severe pain (PEG score ≥ 4), of whom 56% reported current pain treatment and 15% stated that they might ask for help. For a PEG score cutoff of 4 or greater, sensitivity was 0.81 and specificity was 0.78 to find scores of 4 or greater on one or both BPI subscales during the interview. For the question on need for treatment, replies on the screener and the interview were not always consistent. Of the 43 interviewed participants with a PEG score of 4 or greater, 60% received treatment. Of the 17 without current pain treatment, 10 still reported pain, three of whom said that they might ask for help. CONCLUSION: The PEG can be used as a postal screener to detect the presence of pain in older persons, but treatment needs cannot be established using the PEG alone or in combination with a simple additional question.

Symptoms and treatment when death is expected in dementia patients in long-term care facilities.

BACKGROUND: Although dementia at the end of life is increasingly being studied, we lack prospective observational data on dying patients. In this study symptoms were observed in patients with dementia in the last days of life. METHODS: When the elderly care physicians in two Dutch nursing homes expected death within one week, symptoms of (dis)comfort, pain and suffering were observed twice daily. For this the Pain Assessment in Advanced Dementia (PAINAD; range 0-10), Discomfort Scale-Dementia of Alzheimer Type (DS-DAT; range 0-27), End-Of-Life in Dementia-Comfort Assessment in Dying (EOLD-CAD; range 14-42) and an adapted version of the Mini-Suffering State Examination (MSSE; range 0-9), were used. Information on care, medical treatment and treatment decisions were also collected. RESULTS: Twenty-four participants (median age 91 years; 23 females), were observed several times (mean of 4.3 observations (SD 2.6)), until they died. Most participants (n = 15) died from dehydration/cachexia and passed away quietly (n = 22). The mean PAINAD score was 1.0 (SD 1.7), DS-DAT 7.0 (SD 2.1), EOLD-CAD 35.1 (SD 1.7), and MSSE 2.0 (SD 1.7). All participants received morphine, six received antibiotics, and rehydration was prescribed once. CONCLUSION: In these patients with dementia and expected death, a low symptom burden was observed with validated instruments, also in dehydrated patients without aggressive treatment. A good death is possible, but might be enhanced if the symptom burden is regularly assessed with validated instruments. The use of observation tools may have influenced the physicians to make treatment decisions.

[Hip fracture in patients with dementia: surgery is not always the best alternative]. / Heupfractuur bij patiënten met dementie; opereren niet altijd vanzelfsprekend.

Patients with dementia are at risk of hip fracture. The prognosis of rehabilitation after surgery is less favourable than in the general population, because of higher mortality, more complications and a longer rehabilitation period. We present 2 female patients with dementia (77 and 86 years old) who each received a different therapy: one surgical, the other conservative. Dutch elderly care physicians make use of advance care planning to determine how to make medical decisions. The policy for treatment might be curative, palliative or symptomatic. When making a medical decision, it is important to consider if a treatment is effective, proportional and if the intended outcome is desirable. In some cases of hip fracture in patients with dementia, conservative treatment and withholding surgery can be good care. More investigation is needed for further evidence-based decision-making.

Nonreferral of nursing home patients with suspected breast cancer.

INTRODUCTION: People with suspected breast cancer who are not referred for diagnostic testing remain unregistered and are not included in cancer statistics. Little is known about the extent of and motivation for nonreferral of these patients. METHODS: A Web-based survey was sent to all elderly care physicians (ECPs) registered at the National Association of Elderly Care Physicians and Social Geriatricians in the Netherlands, inquiring about the number of patients with suspected breast cancer they encountered and subsequent choices regarding referral. RESULTS: Surveys were completed by 419 (34%) of 1239 ECPs; 249 (60%) of these had encountered one or more patients with suspected breast cancer in the past year. Seventy-four (33%) ECPs reported not referring the last patient. Reasons for nonreferral were end-stage dementia (57%), patient/family preference (29%), and limited life expectancy (23%). Referral was frequently thought to be too burdensome (13%). For 16% of nonreferred patients, hormonal treatment was started by the ECP without diagnostic confirmation of cancer. CONCLUSION: In this survey, more than 33% of nursing home patients with suspected breast cancer were not referred for further testing, in particular those with advanced dementia, limited life expectancy, and poor functional status. As the combination of dementia and suspected breast cancer is expected to double in the coming decades, now is the time to optimize cancer care for these vulnerable patients.

Pain in European long-term care facilities: cross-national study in Finland, Italy and The Netherlands.

There have been very few and limited cross-national comparisons concerning pain among residents of long-term care facilities in Europe. The aim of the present cross-sectional study has been to document the prevalence of pain, its frequency and severity as well as its correlates in three European countries: Finland (north), Italy (south) and the Netherlands (western central). Patients (aged 65years or above) were assessed with the Minimum Data Set 2.0 (MDS).The final sample comprised 5761 patients from 64 facilities in Finland, 2295 patients from 8 facilities in the Netherlands and 1959 patients from 31 facilities in Italy. The prevalence of pain - defined as any type of pain - varied between 32% in Italy, 43% in the Netherlands and 57% in Finland. In nearly 50% of cases, pain was present daily; there were no significant differences in pain prevalence between patients with cancer diagnosis and those with non-cancer diagnosis. Regardless of the different prevalence estimates, pain was moderate-to-severe in over 50% of cases in all the countries. In multivariate logistic regression models, clinical correlates of pain were substantially similar across countries: pain was positively correlated with more severe physical disability (ADL impairment), clinical depression and a diagnosis of osteoporosis. Pain was negatively correlated with a diagnosis of dementia and more severe degrees of cognitive deterioration. We conclude that pain is frequently encountered in long-term care facilities in Europe and that, despite cultural and case-mix differences, pain speaks one language.