Personality Disorders in Older Adults: a Review of Epidemiology, Assessment, and Treatment.

PURPOSE OF REVIEW: The aim of the paper is reviewing recent literature on the epidemiology, assessment, and treatment of personality disorders (PDs) among older adults (≥ 60 years). RECENT FINDINGS: Since 2015, 12 primary empirical studies have been published addressing PDs in older adults; 3 addressing epidemiological aspects, 6 on assessment, 2 exploring both epidemiology and assessment, and 1 examining treatment. PD research in older adults is steadily growing and is predominantly focused on assessment. The studies showed that PDs were rather prevalent ranging from 10.6-14.5% in community-dwelling older adults, to 57.8% in nursing home-residing older adults. The Severity Indices of Personality Problems-Short Form, Gerontological Personality disorders Scale, and Assessment of DSM-IV Personality Disorders turned out to be promising instruments for assessing PDs in later life. Furthermore, schema therapy seems to be a feasible and effective intervention. Despite promising findings, there is an urgent need for studies addressing PDs in older adults, especially studies investigating epidemiological aspects and treatment options. Furthermore, new areas of interest arise such as PDs in other settings, and behavioral counseling.

Patients' and partners' illness perceptions in screen-detected versus clinically diagnosed type 2 diabetes: partners matter!

BACKGROUND: In type 2 diabetes, educational interventions that target differences between patients' and partners' illness perceptions have been advocated. OBJECTIVE: To investigate how the route to diagnosis of type 2 diabetes (through screening versus clinical symptoms) affects illness perceptions of patients and their partners. METHODS: In a cross-sectional study, we enrolled patients aged 40-75 years from general practices in the Netherlands with a new diagnosis of type 2 diabetes (≤3 years), detected by either screening (n = 77) or clinical symptoms (n = 32). Patients and their partners each completed a postal Brief Illness Perception Questionnaire (Brief IPQ), and up-to-date clinical data were obtained from their GP. The Brief IPQ scores of the screening and clinical diagnosis groups were compared for both patients and partners, and multiple variable linear regression models with Brief IPQ scores as outcomes were developed. RESULTS: The route to diagnosis did not appear to have a strong influence on patients' illness perceptions but did influence illness perceptions of their partners. Partners of patients diagnosed through screening perceived greater consequences for their own life, had a stronger feeling that their patient-partners had control over their diabetes, were more concerned about their partners' diabetes, and believed that their patient-partners experienced more diabetes symptoms, compared with partners of patients who were diagnosed through clinical symptoms. CONCLUSIONS: The route to diagnosis of type 2 diabetes has a greater impact on the illness perceptions of partners than that of patients. Professionals in diabetes education and treatment should consider these differences in their approach to patient care.

End-of-life decisions for people with intellectual disabilities, an interview study with patient representatives.

BACKGROUND: Not much is known about the process of end-of-life decision-making for people with intellectual disabilities. AIM: To clarify the process of end-of-life decision-making for people with intellectual disabilities from the perspective of patient representatives. DESIGN: A qualitative study based on semi-structured interviews, recorded digitally and transcribed verbatim. Data were analysed using Grounded Theory procedures. PARTICIPANTS: We interviewed 16 patient representatives after the deaths of 10 people with intellectual disabilities in the Netherlands. RESULTS: The core category 'Deciding for someone else' describes the context in which patient representatives took end-of-life decisions. The patient representatives felt highly responsible for the outcomes. They had not involved the patients in the end-of-life decision-making process, nor any professionals other than the doctor. The categories of 'Motives' and 'Support' were connected to the core category of 'Deciding for someone else'. 'Motives' refers to the patient representatives' ideas about quality of life, prevention from suffering, patients who cannot understand the burden of interventions and emotional reasons reported by patient representatives. 'Support' refers to the support that patient representatives wanted the doctors to give to them in the decision-making process. CONCLUSIONS: From the perspective of the patient representatives, the process of end-of-life decision-making can be improved by ensuring clear roles and an explicit description of the tasks and responsibilities of all participants. Regular discussion between everyone involved including people with intellectual disabilities themselves can improve knowledge about each other's motives for end-of-decisions and can clarify expectations towards each other.

Assessment of appropriateness of screening community-dwelling older people to prevent functional decline.

OBJECTIVES: To identify appropriate screening conditions, stratified according to age and vulnerability, to prevent functional decline in older people. DESIGN: A RAND/University of California at Los Angeles appropriateness method. SETTING: The Netherlands. PARTICIPANTS: A multidisciplinary panel of 11 experts. MEASUREMENTS: The panelists assessed the appropriateness of screening for 29 conditions mentioned in guidelines from four countries, stratified according to age (60-74, 75-84, ≥85) and health status (general, vital, and vulnerable) and received a literature overview for each condition, including the guidelines and up-to-date literature. After an individual rating round, panelists discussed disagreements and performed a second individual rating. The median of the second ratings defined the appropriateness of screening. RESULTS: The panel rated screening to be appropriate in three of the 29 conditions, indicating that screening was expected to prevent functional decline. Screening for insufficient physical activity was considered appropriate for all three age and health groups. Screening for cardiovascular risk factors and smoking was considered appropriate for the general and vital population aged 60 to 74. Of the 261 ratings, 63 (24%) were classified as uncertain, of which 42 (67%) concerned the vulnerable population. The panelists considered conditions inappropriate mainly because of lack of an adequate screening tool or lack of evidence of effective interventions for positive screened persons. CONCLUSION: The expert panel considered screening older people to prevent functional decline appropriate for insufficient physical activity and smoking and cardiovascular risk in specific groups. For other conditions, sufficient evidence does not support screening. Based on their experience, panelists expected benefit from developing tests and interventions, especially for vulnerable older people.

The value of nurse practitioners in Dutch general practices.

BACKGROUND: Healthcare systems are faced with a changing and increasing demand for care. Against the background of the need to increase service capacity and to improve access to primary care, a project was initiated to introduce the nurse practitioner (NP) role into Dutch general practices. OBJECTIVE: To explore the value of the NP by describing NP roles and their concordance with the initial concepts of the NP training programme. METHODS: An observational longitudinal design, using mixed methods, was conducted between March 2004 and June 2008. A convenience sample of seven NPs and seven teaching general practitioners (GPs), together constituting seven experimental groups, was used. Project documentation and data from consultations between NPs and GPs were collected. Twenty-nine interviews were performed, focusing on NP roles, competencies of NPs and collaboration between professionals. RESULTS: As was anticipated, all NPs have patients with common complaints as their main focus, as well as managing the quality of care projects. Differences between NPs are reported in the percentages of time spent in performing home visits, caring for older people, patient related activities and non-patient related activities. CONCLUSION: NPs contribute to the accessibility and availability of primary care as well as to collaboration in and quality of primary care. The roles they adopt are influenced by practice needs and financial incentives. It is not clear to what degree NPs have to perform activities to improve quality of care and further research is necessary to define NP core competencies.

Economic evaluation of nurse practitioners versus GPs in treating common conditions.

BACKGROUND: As studies evaluating substitution of care have revealed only limited evidence on cost-effectiveness, a trial was conducted to evaluate nurse practitioners as a first point of contact in Dutch general practices. AIM: To estimate costs of GP versus nurse practitioner consultations from practice and societal perspectives. DESIGN OF STUDY: An economic evaluation was conducted alongside a randomised controlled trial between May and October 2006, wherein 12 nurse practitioners and 50 GPs working in 15 general practices (study practices) participated. Consultations by study practices were also compared with an external reference group, with 17 GPs working in five general practices without the involvement of nurse practitioners. METHOD: Direct costs within the healthcare sector included resource use, follow-up consultations, length of consultations, and salary costs. Costs outside the healthcare sector were productivity losses. Sensitivity analyses were performed. RESULTS: Direct costs were lower for nurse practitioner consultations than for GP consultations at study practices. This was also the case for direct costs plus costs from a societal perspective for patients aged <65 years. Direct costs of consultations at study practices were lower than those of reference practices, while practices did not differ for direct costs plus costs from a societal perspective for patients aged <65 years. Cost differences are mainly caused by the differences in salary. CONCLUSION: By involving nurse practitioners, substantial economic 'savings' could be used for redesigning primary care, to optimise the best skill mix, and to cover the full range of primary care activities.

Economic evaluation of a minimal psychological intervention in chronically ill elderly patients with minor or mild to moderate depression: a randomized trial (the DELTA-study).

OBJECTIVES: Depression is associated with high healthcare utilization and related costs. Effective treatments might reduce the economic burden. The objective of this study was to establish the cost-utility of a minimal psychological intervention (MPI) aimed at reducing depression and improving quality of life in elderly persons with diabetes or chronic obstructive pulmonary disease and co-occurring minor, mild, or moderate depression. METHODS: Trial-based cost-utility analysis was used to compare the MPI with usual care. Annual costs and quality-adjusted life-years (QALYs) based on the Euroqol (EQ5D) and on depression-free days were calculated. RESULTS: Annual costs and effects were not significantly different for the MPI group and care as usual. Bootstrap analysis indicated a dominant intervention, with a probability of 63 percent that the MPI is less costly and more effective than usual care. CONCLUSIONS: The cost-effectiveness analysis does not support dissemination of the MPI in its current form. The economic evaluation study showed limited probability that MPI is cost-effective over usual care. Further adjustments to the MPI are needed to make the intervention suitable for dissemination in regular care. TRIAL REGISTRATION: isrctn.org, identifier: ISRCTN92331982.

Reflection: a link between receiving and using assessment feedback.

PROBLEM STATEMENT AND BACKGROUND: Feedback is essential to learning and practice improvement, yet challenging both to provide and receive. The purpose of this paper was to explore reflective processes which physicians described as they considered their assessment feedback and the perceived utility of that reflective process. METHODS: This is a qualitative study using principles of grounded theory. We conducted interviews with 28 family physicians participating in a multi-source feedback program and receiving scores across the spectrum from high to low. RESULTS: Feedback, especially negative feedback, evoked reflective responses. Reflection seemed to be the process through which feedback was or was not assimilated and appeared integral to decisions to accept and use the feedback. Facilitated reflection upon feedback was viewed as a positive influence for assimilation and acceptance. CONCLUSIONS: Receiving feedback inconsistent with self-perceptions stimulated physicians' reflective processes. The process of reflection appeared instrumental to feedback acceptance and use, suggesting that reflection may be an important educational focus in the formative assessment and feedback process.

Clinical and cost-effectiveness of computerised cognitive behavioural therapy for depression in primary care: design of a randomised trial.

BACKGROUND: Major depression is a common mental health problem in the general population, associated with a substantial impact on quality of life and societal costs. However, many depressed patients in primary care do not receive the care they need. Reason for this is that pharmacotherapy is only effective in severely depressed patients and psychological treatments in primary care are scarce and costly. A more feasible treatment in primary care might be computerised cognitive behavioural therapy. This can be a self-help computer program based on the principles of cognitive behavioural therapy. Although previous studies suggest that computerised cognitive behavioural therapy is effective, more research is necessary. Therefore, the objective of the current study is to evaluate the (cost-) effectiveness of online computerised cognitive behavioural therapy for depression in primary care. METHODS/DESIGN: In a randomised trial we will compare (a) computerised cognitive behavioural therapy with (b) treatment as usual by a GP, and (c) computerised cognitive behavioural therapy in combination with usual GP care. Three hundred mild to moderately depressed patients (aged 18-65) will be recruited in the general population by means of a large-scale Internet-based screening (N = 200,000). Patients will be randomly allocated to one of the three treatment groups. Primary outcome measure of the clinical evaluation is the severity of depression. Other outcomes include psychological distress, social functioning, and dysfunctional beliefs. The economic evaluation will be performed from a societal perspective, in which all costs will be related to clinical effectiveness and health-related quality of life. All outcome assessments will take place on the Internet at baseline, two, three, six, nine, and twelve months. Costs are measured on a monthly basis. A time horizon of one year will be used without long-term extrapolation of either costs or quality of life. DISCUSSION: Although computerised cognitive behavioural therapy is a promising treatment for depression in primary care, more research is needed. The effectiveness of online computerised cognitive behavioural therapy without support remains to be evaluated as well as the effects of computerised cognitive behavioural therapy in combination with usual GP care. Economic evaluation is also needed. Methodological strengths and weaknesses are discussed. TRIAL REGISTRATION: The study has been registered at the Netherlands Trial Register, part of the Dutch Cochrane Centre (ISRCTN47481236).

"Directed" self-assessment: practice and feedback within a social context.

INTRODUCTION: Accurate self-assessment appears to be difficult and, some would propose, even impossible. Recent reviews suggest that peer assessment may be more accurate and that multisource feedback (MSF) may inform self-assessment. We had conducted a series of studies of family physicians in an MSF program including assessments from patients, medical colleagues, and coworkers and self-assessment. Using this body of research, this article explores self-assessment within the social context of multisource feedback and investigates the influence of feedback from peers and others upon self-assessment. METHODS: This is a review article in which we synthesized findings of the series of studies with respect to self-assessment, used conclusions to propose a model for self-assessment within a social context, and suggest practical and research implications. RESULTS: Physicians compared peers' and others' assessment feedback with global self-perceptions of performance. Negative feedback, especially from medical colleagues, that was inconsistent with self-perceptions was not readily reconciled with self-assessments. Multiple internal and environmental factors influenced reconciliation and assimilation of negative feedback. Reflection upon feedback and self-perceptions appeared to be instrumental to reconciliation, and reflection could be facilitated. DISCUSSION: We propose a model of "directed" self-assessment to facilitate the integration of external feedback, especially negative feedback, with self-perceptions and enable its use for practice improvement. Implications for education and research include increasing understanding of ways physicians assimilate external feedback and of the role of educators as facilitators of "directed" self-assessment and self-learning to assist physicians in integrating external feedback.

The SMILE study: a study of medical information and lifestyles in Eindhoven, the rationale and contents of a large prospective dynamic cohort study.

BACKGROUND: Health problems, health behavior, and the consequences of bad health are often intertwined. There is a growing need among physicians, researchers and policy makers to obtain a comprehensive insight into the mutual influences of different health related, institutional and environmental concepts and their collective developmental processes over time. METHODS/DESIGN: SMILE is a large prospective cohort study, focusing on a broad range of aspects of disease, health and lifestyles of people living in Eindhoven, the Netherlands. This study is unique in its kind, because two data collection strategies are combined: first data on morbidity, mortality, medication prescriptions, and use of care facilities are continuously registered using electronic medical records in nine primary health care centers. Data are extracted regularly on an anonymous basis. Secondly, information about lifestyles and the determinants of (ill) health, sociodemographic, psychological and sociological characteristics and consequences of chronic disease are gathered on a regular basis by means of extensive patient questionnaires. The target population consisted of over 30,000 patients aged 12 years and older enrolled in the participating primary health care centers. DISCUSSION: Despite our relatively low response rates, we trust that, because of the longitudinal character of the study and the high absolute number of participants, our database contains a valuable set of information.SMILE is a longitudinal cohort with a long follow-up period (15 years). The long follow-up and the unique combination of the two data collection strategies will enable us to disentangle causal relationships. Furthermore, patient-reported characteristics can be related to self-reported health, as well as to more validated physician registered morbidity. Finally, this population can be used as a sampling frame for intervention studies. Sampling can either be based on the presence of certain diseases, or on specific lifestyles or other patient characteristics.

Critical appraisal of the literature on economic evaluations of substitution of skills between professionals: a systematic literature review.

OBJECTIVE: Substitution of skills has been introduced to increase health service efficiency, but little evidence is available about its cost-effectiveness. This systematic review aims to identify economic evaluations of substitution between professionals, to assess the quality of the study methods applied and to value the results for decision making. METHODS: Publications between January 1996 and November 2006 were searched in Medline, Cochrane, Cinahl, database of Health Technology Assessments, EPOC and Embase. Randomized controlled trials (RCTs), cost-benefit analysis, interrupted time series design and systematic reviews were selected. The methodological quality of the papers was reviewed, using the critical appraisal of Drummond and the EPOC list. RESULTS: Eleven studies were finally included of 7605 studies: three cost-effectiveness studies, three cost-minimization studies and five studies related to partial economic evaluations. Small numbers of participating professionals and several limitations in the cost valuation and the measurement of costs were identified. CONCLUSIONS: Several potential limitations influence the validity and generalizability. Full economic evaluations per se are of limited value for making decisions about substitution of skills. The tenuous relationship between structural, process and outcome variables is not sufficient investigated. For meaningfully placing the costs and consequences of substitution of skills in the context of health care and generating relevant data for decision making, it is strongly recommended to combine an economic evaluation (RCT) with an observational longitudinal study.

The costs of epilepsy in three different populations of patients with epilepsy.

The purpose of this study was to estimate the costs of care in three different populations of patients with epilepsy (general practices (GP), University Hospital (UH), and Epilepsy Center (EC)), and to analyse the distribution of costs by type of services for each patient group. A cost diary was developed to obtain prospective information on epilepsy-attributable service use over a period of 3 months. Similar information over the previous 3 months was obtained from a cost questionnaire. In addition, a quality of life inventory (QOLIE-31) was used. Standard cost lists were applied for the valuation of the direct cost items. A sensitivity analysis was performed for certain cost items for which no reliable data were available. One hundred and sixteen patients with established epilepsy were included, and the mean costs per patient per month (in Euros) ranged from 52.08 to 357.63. Patients from GP appeared to have lower direct costs, spent less time in seeking or undergoing a treatment, and reported lower seizure frequencies and less severe seizure types than the patients from the other patient groups. Patients from the EC reported the highest productivity changes and unemployment rates and also had the lowest scores on the QOLIE-31. The cost items anti-epileptic drugs, hospital services, unpaid care, and transportation accounted for the majority of the total direct costs.

Is there an increased risk of dying after depression?

Although a lot of research has been performed on the relation between depression and subsequent mortality, the results show contradictory findings. In this study, the authors investigated mortality in depressed people compared with nondepressed people in a large-scale retrospective cohort study based in general practice in the province of Limburg, the Netherlands. All subjects diagnosed with depression between 1975 and 1990 were included and compared with subjects matched on birth year who never were diagnosed with depression. Follow-up ended on April 30, 2000. Hazard ratios and their 95% confidence intervals were calculated using stratified Cox proportional hazards models adjusted for age, sex, and socioeconomic status. Subgroups based on sex and age at the diagnosis of depression were evaluated separately. A total of 68,965 patients were followed for an average of 15 years. Among 1,362 depressed subjects 132 died, and among 67,603 nondepressed subjects 4,256 died. The adjusted hazard ratio for depressed versus nondepressed subjects was 1.39 (95% confidence interval: 1.16, 1.65). A significant interaction was observed between the age at diagnosis of depression and sex. A moderate positive association between depression and subsequent mortality was identified.