Improving the applicability of guidelines on nonmelanoma skin cancer in frail older adults: a multidisciplinary expert consensus and systematic review of current guidelines.

BACKGROUND: Balancing treatment decisions in frail older adults with nonmelanoma skin cancer (NMSC) can be challenging. Clinical practice guidelines (CPGs) could provide assistance. OBJECTIVES: To collect and prioritize items related to frail older adults with NMSC for integration into CPGs and to assess the current extent of this integration. METHODS: Items were collected and prioritized by a multidisciplinary working group (29 members) using a modified Delphi procedure and a five-point Likert scale. To assess current integration of these items in CPGs, a systematic review was subsequently performed by two independent reviewers using five medical databases (PubMed, Embase, Cochrane Library, SUMsearch and Trip Database), websites of guideline developers/databases, and (inter)national dermatological societies. RESULTS: Prioritization of a final 13-item list showed that 'limited life expectancy' (4·5 ± 0·9) and 'treatment goals other than cure' (4·4 ± 0·7) were most desired to be integrated into CPGs; both were included in six (46%) of the CPGs found (n = 13). Attention to 'tumour characteristics' and 'comorbidities' were included in CPGs most often (100% and 77%, respectively). CONCLUSIONS: More attention to items related to frail older adults in NMSC CPGs is broadly desired, but CPG integration of these items is currently limited. More integration might stimulate more holistic, personalized and patient-centred care in frail older adults.

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.

[Medically unexplained symptoms in older adults: a combination of physical, psychiatric and psychological factors]. / Onverklaarde lichamelijke klachten bij ouderen: samenspel van lichamelijke, psychiatrische en psychologische factoren.

3 women aged 75, 75 and 65 years, respectively, were referred to an outpatient clinic for medically unexplained symptoms (MUS). These cases illustrate the heterogeneity and complexity of MUS in elderly patients, which requires broad, multidisciplinary clinical examination by a geriatrician, psychiatrist and psychologist. The first patient presented with persistent pain in the lower back and legs. Examination revealed a spinal stenosis, which was treated surgically; symptoms subsequently resolved. The second patient had chronic abdominal pain and constipation in combination with depression. She was diagnosed with a severe depressive disorder. After adequate drug treatment, her mood improved and the somatic symptoms disappeared. The third patient complained of headache and feared that she may have a brain tumour. There was no somatic diagnosis. She underwent cognitive behavioural group therapy, which substantially improved her functioning. These cases illustrate the diversity and complexity of MUS in elderly patients and underscore the diagnostic appropriateness of the biopsychosocial paradigm. A specialised multidisciplinary examination ensures accurate diagnosis and cognitive behavioural therapy.

[The recommended reference values for anaemia in the elderly are of limited usefulness]. / Aanbevolen grenswaarden voor anemie bij oude mensen beperkt bruikbaar.

Recent epidemiological findings on the risk factors for mortality and functional impairment do not support lower cut-off values than the official WHO reference values for the definition of anaemia in the elderly, and even suggest higher limits. However, wide-scale application of such high Hb values for a full investigation of the causes of anaemia in clinical practice requires data on the effectiveness in terms of a net increase in quality of life at acceptable costs. At present, there are no evidence-based Hb limits for the elderly because such data are lacking. As a pragmatic way out, the WHO limits can be taken for a simple and non-invasive biochemical analysis of anaemia, but individual considerations, taking into account co-morbidity, life expectation and patients' preferences, are necessary for further diagnostic investigations such as colonoscopy or sternum puncture.

[Summary of the Dutch College of General Practitioners' practice guideline 'Delirium in elderly people']. / Samenvatting van de standaard 'Delier bij ouderen' van het Nederlands Huisartsen Genootschap.

The Dutch College of General Practitioners' practice guideline 'Delirium in elderly people' contains a number of key messages. These are: Consider the diagnosis of delirium in the case of changes in consciousness and attention, incoherent thinking or disorientation, if this picture developed over a short period of time (hours to days) and if the symptoms vary over the 24-hour period. Delirium is provoked by one or more somatic disorders; investigation and treatment of these disorders is an essential part of managing delirium. It is often difficult to distinguish delirium from dementia and depression. Although delirium is generally reversible, the prognosis in the elderly is relatively poor. If delirium is accompanied by fear or agitation, haloperidol is the drug of first choice, but in delirium induced by alcohol withdrawal or benzodiazepine withdrawal, a short-acting benzodiazepine such as lorazepam or oxazepam is indicated. Part of the treatment, but also prevention of delirium is focused on inducing factors that can provoke a delirium, such as medication with an anticholinergic effect, polypharmacy, inadequate nutrition, dehydration, sleep deprivation, immobility and sensory handicaps.

[Medical-scientific research in the elderly in The Netherlands; historic milestones and methodological problems]. / Medisch-wetenschappelijk onderzoek bij ouderen in Nederland; historische mijlpalen en methodologische problemen.

OBJECTIVE: To describe the methodological development of medical research regarding elderly subjects in the Netherlands. DESIGN: Descriptive. SETTING: Nijmegen University, the Netherlands. METHOD: All research on aging published in the Netherlands Tijdschrift voor Geneeskunde (Dutch Journal of Medicine) starting from its first volume in 1857 up to 1983 was studied. Selected were those articles in which new research methods were introduced. Next, six pioneering researchers in geriatrics were interviewed on the methodological development of geriatric research and on the problems they encountered in their own research. RESULTS: Research started with studies on age-associated diseases such as prostatism, presbyacusis and senile dementia. It was only after a considerable delay that new diagnostic instruments such as electrocardiography and new research designs such as randomized trials found their way into research on elderly patients. The development of a questionnaire on the health of the elderly, the introduction of the concept of activities of daily living and of diagnostic instruments in the field of psychogeriatrics were important steps that made possible current geriatric research. From the outset, researchers encountered methodological problems still relevant in current research and caused by characteristics of geriatric patients: frailty, high prevalence of comorbidity, coexistence of physical, psychological and social problems, and large interindividual differences.

[Polypharmacy in patients of a geriatric department of a general hospital]. / Polyfarmacie bij patiënten op een GAAZ.

At three somato-geriatric and one psychogeriatric units in the Amsterdam 'Slotervaartziekenhuis', retrospective research into the use of drugs by all patients admitted in 1985 (n = 724) was conducted. The main aim was to answer the question whether geriatric treatment can reduce the hitherto frequently described polypharmacy of the elderly. For that purpose the medication of all patients is registered as from their admission into hospital until the time of discharge from hospital. The average number of drugs used in the hospital appeared to have increased from 2.8 on admission to 3.8 on discharge. Geriatricians in Amsterdam were unable to reduce polypharmacy, probably because of the multiple pathology of their patients (4.4 diagnoses on discharge per patient). Yet, they prescribed only 0.86 drug per diagnosis on average. The most frequently prescribed drugs were vitamins, laxatives, diuretics, analgetics, sedatives/hypnotics and cardiovascular drugs. Antibiotics were used by a large percentage (46%) of the patients. On admission clearly fewer drugs (2.4) were used by patients who lived independently than by patients from residential and nursing homes (respectively 4.1 and 3.6). Eight percent of the patients was admitted because of adverse drug reactions or intoxications. On admission they used an average number of 4.1 drugs daily, which is considerably more than the number (2.7) used by other patients. Their drug use of course was reconsidered during their stay at the geriatric department.