Assessing the perspective of well-being of older patients with multiple morbidities by using the LAVA tool - a person-centered approach.

BACKGROUND: Older patients with multiple morbidities are a particularly vulnerable population that is likely to face complex medical decisions at some time in their lives. A patient-centered medical care fosters the inclusion of the patients' perspectives, priorities, and complaints into clinical decision making. METHODS: This article presents a short and non-normative assessment tool to capture the priorities and problems of older patients. The so-called LAVA ("Life and Vitality Assessment") tool was developed for practical use in seniors in the general population and for residents in nursing homes in order to gain more knowledge about the patients themselves as well as to facilitate access to the patients. The LAVA tool conceptualizes well-being from the perspectives of older individuals themselves rather than from the perspectives of outside individuals. RESULTS: The LAVA tool is graphically presented and the assessment is explained in detail. Exemplarily, the outcomes of the assessments with the LAVA of three multimorbid older patients are presented and discussed. In each case, the assessment pointed out resources as well as at least one problem area, rated as very important by the patients themselves. CONCLUSIONS: The LAVA tool is a short, non-normative, and useful approach that encapsulates the perspectives of well-being of multimorbid patients and gives insights into their resources and problem areas.

Treatable Vascular Risk and Cognitive Performance in Persons Aged 35 Years or Older: Longitudinal Study of Six Years.

BACKGROUND: Poor cognitive performance is associated with high vascular risk. However, this association is only investigated in elderly. As neuropathological changes precede clinical symptoms of cognitive impairment by several decades, it is likely that cognitive performance is already associated with vascular risk at middle-age. OBJECTIVES: To investigate the association of cognitive performance with treatable vascular risk in middle-aged and old persons. DESIGN: Longitudinal study with three measurements during follow-up period of 5.5 years. SETTING: City of Groningen, the Netherlands. PARTICIPANTS: Cohort of 3,572 participants (age range, 35-82 years; mean age, 54 years; men, 52%). EXPOSURE: Treatable vascular risk as defined by treatable components of the Framingham Risk Score for Cardiovascular Disease at the first measurement (diabetes mellitus, smoking, hypercholesterolemia and hypertension). MEASUREMENTS: Change in cognitive performance during follow-up. Cognitive performance was measured with Ruff Figural Fluency Test (RFFT) and Visual Association Test (VAT), and calculated as the average of the standardized RFFT and VAT score per participant. RESULTS: The mean (SD) cognitive performance changed from 0.00 (0.79) at the first measurement to 0.15 (0.83) at second measurement and to 0.39 (0.82) at the third measurement (Ptrend<0.001). This change was negatively associated with treatable vascular risk: the change in cognitive performance between two measurements decreased with 0.004 per one-point increment of treatable vascular risk (95%CI, -0.008 to 0.000; P=0.05) and with 0.006 per one-year increment of age (95%CI, -0.008 to -0.004; P<0.001). CONCLUSIONS: Change in cognitive performance was associated with treatable vascular risk in persons aged 35 years or older.

This is an older men's world: A qualitative study of men's experiences with prostate cancer.

PURPOSE: Prostate cancer is highly prevalent and invasive among older men. Not knowing their experiences hampers care and support to men with prostate cancer and prostate cancer survivors. This study aims to provide insight into older men's experiences with prostate cancer in order to improve personalised care. METHODS: A qualitative research design through semi-structured interviews with 22 older men with prostate cancer was conducted in two areas of the Netherlands in 2015. Patients were selected through systematic non-probabilistic sampling. The transcripts were analysed with conventional content analysis and affinity diagramming. RESULTS: Four themes emerged from the data: impact of prostate cancer, dealing with prostate cancer and treatment, involvement of and with others, and experiences with professional care and the care trajectory. The way patients dealt with prostate cancer and their experiences with the care they received varied. Overall, hospital care was rated positively, and communication was a crucial determinant of the patient's satisfaction or dissatisfaction. Some patients lacked information about their health status, which may have influenced decision-making processes. Some were reluctant to talk about their disease with other people and sometimes hesitated to ask for help. CONCLUSION: Despite many positive care experiences, some patients felt that the communication, information provision and decision-making were inadequate. Vulnerable patients with severe complications or limited social support may need additional psychosocial care. Lowering the threshold for patients to ask for help and the availability of a professional with expert knowledge about prostate cancer and ageing may decrease unnecessary hardship and increase personal strengths.

[Medical treatment of people with dementia requires dealing with uncertainty]. / Medisch handelen bij mensen met dementie is omgaan met onzekerheid.

Here we report on a number of medical dilemmas during the final 6 years of life of a 78-year-old woman with dementia. Questions concerning both diagnostic procedures and treatment options are discussed. The first dilemma concerns mild symptoms leading to the diagnosis of paroxysmal atrial fibrillation and the requirement for anticoagulation; the second dilemma concerns vague symptoms of tiredness with anaemia leading to the diagnosis of colon cancer and the requirement for surgery. The conclusion is that there are no protocols that can be used to solve questions of this nature, and we need careful reflection with colleagues, the patient and important people in the patient's life in order to make decisions in the best interest of the quality of life as experienced by the patient. This is a complicated task for any doctor who has to deal with medical uncertainties and an incapacitated patient.

Complications during hospitalization and risk factors in elderly patients with hip fracture following integrated orthogeriatric treatment.

INTRODUCTION: This study aimed to evaluate the incidence of complications in elderly patients with a hip fracture following integrated orthogeriatric treatment. To discover factors that might be adjusted, in order to improve outcome in those patients, we examined the association between baseline patient characteristics and a complicated course. METHODS: We included patients aged 70 years and older with a hip fracture, who were treated at the Centre for Geriatric Traumatology (CvGT) at Ziekenhuisgroep Twente (ZGT) Almelo, the Netherlands between April 2011 and October 2013. Data registration was carried out using the clinical pathways of the CvGT database. Based on the American Society of Anesthesiologists (ASA) score, patients were divided into high-risk (HR, ASA 3 ≥, n = 341) and low-risk (LR, ASA 1-2, n = 111) groups and compared on their recovery. Multivariate logistic regression was used to identify risk factors for a complicated course. RESULTS: The analysis demonstrated that 49.6% (n = 224) of the patients experienced a complicated course with an in-hospital mortality rate of 3.8% (n = 17). In 57.5% (n = 196) of the HR patients, a complicated course was seen compared to 25.2% (n = 28) of the LR patients. The most common complications in both groups were the occurrence of delirium (HR 25.8% vs. LR 8.1%, p ≤ 0.001), anemia (HR 19.4% vs. LR 6.3%, p = 0.001), catheter-associated urinary tract infections (CAUTIs) (HR 10.6% vs. LR 7.2%, p = 0.301) and pneumonia (HR 10.9% vs. LR 5.4%, p = 0.089). Independent risk factors for a complicated course were increasing age (OR 1.04, 95% CI 1.01-1.07, p = 0.023), delirium risk VMS Frailty score (OR 1.57, 95% CI 1.04-2.37, p = 0.031) and ASA score ≥3 (OR 3.62, 95% CI 2.22-5.91, p ≤ 0.001). CONCLUSIONS: After integrated orthogeriatric treatment, a complicated course was seen in 49.6% of the patients with a hip fracture. The in-hospital mortality rate was 3.8%. Important risk factors for a complicated course were increasing age, poor medical condition and delirium risk VMS Frailty score. Awareness of risk factors that affect the course during admission can be useful in optimizing care and outcomes. In the search for possible areas for improvement in care, targeted preventive measures to mitigate delirium, and healthcare-associated infections (HAIs), such as CAUTIs and pneumonia are important.

Improved 1-year mortality in elderly patients with a hip fracture following integrated orthogeriatric treatment.

To improve the quality of care and reduce the healthcare costs of elderly patients with a hip fracture, surgeons and geriatricians collaborated intensively due to the special needs of these patients. After treatment at the Centre for Geriatric Traumatology (CvGT), we found a significant decrease in the 1-year mortality rate in frail elderly patients compared to the historical control patients who were treated with standard care. INTRODUCTION: The study aimed to evaluate the effect of an orthogeriatric treatment model on elderly patients with a hip fracture on the 1-year mortality rate and identify associated risk factors. METHODS: This study included patients, aged 70 years and older, who were admitted with a hip fracture and treated in accordance with the integrated orthogeriatric treatment model of the CvGT at the Hospital Group Twente (ZGT) between April 2008 and October 2013. Data registration was carried out by several disciplines using the clinical pathways of the CvGT database. A multivariate logistic regression analysis was used to identify independent risk factors for 1-year mortality. The outcome measures for the 850 patients were compared with those of 535 historical control patients who were managed under standard care between October 2002 and March 2008. RESULTS: The analysis demonstrated that the 1-year mortality rate was 23.2 % (n = 197) in the CvGT group compared to 35.1 % (n = 188) in the historical control group (p < 0.001). Independent risk factors for 1-year mortality were male gender (odds ratio (OR) 1.68), increasing age (OR 1.06), higher American Society of Anesthesiologists (ASA) score (ASA 3 OR 2.43, ASA 4-5 OR 7.05), higher Charlson Comorbidity Index (CCI) (CCI 1-2 OR 1.46, CCI 3-4 OR 1.59, CCI 5 OR 2.71), malnutrition (OR 2.01), physical limitations in activities of daily living (OR 2.35), and decreasing Barthel Index (BI) (OR 0.96). CONCLUSION: After integrated orthogeriatric treatment, a significant decrease was seen in the 1-year mortality rate in the frail elderly patients with a hip fracture compared to the historical control patients who were treated with standard care. The most important risk factors for 1-year mortality were male gender, increasing age, malnutrition, physical limitations, increasing BI, and medical conditions. Awareness of risk factors that affect the 1-year mortality can be useful in optimizing care and outcomes. Orthogeriatric treatment should be standard for elderly patients with hip fractures due to the multidimensional needs of these patients.

Patient navigation and activation interventions for elderly patients with cancer: A systematic review.

Patient navigation (PN) and patient activation (PA) interventions are widely used to help patients with cancer to manage the disease and the care trajectory. However, the usability and impact of these interventions on older patients and their well-being are unclear. This study aims to show which PN and PA interventions are being used and what impact they have. After systematically searching the literature, we assessed the quality of the publications we found. The publications had to involve at least a subgroup of older people with minimally one abnormal oncologic test result each, and they had to focus on PN or PA interventions. Six PA publications examined the interventions exclusively for elderly patients. Each of the 11 PN and PA publications contained at least one comment about the impact on older patients. The types of impact varied substantially, but there was scant attention to the quality of life. The type of intervention, the outcome measures and the quality of publications also varied considerably. Generally, age is not an important factor in PN and PA studies. To facilitate adjustment of navigation and activation interventions to the individual patient, more rigorous research into the impact of PN and PA interventions on older patients is necessary.

Prediction of early mortality following hip fracture surgery in frail elderly: The Almelo Hip Fracture Score (AHFS).

BACKGROUND: Hip fractures are common in the elderly and have a high risk of early mortality. Identification of patients at high risk of early mortality could contribute to enhanced quality of care. A simple scoring system is essential for preoperative identification of patients at high risk of early mortality in clinical practice. Of risk models published, The Nottingham Hip Fracture Score (NHFS) shows the most promising results so far. However, there is still room for improvement. METHODS: A cohort study including 850 patients was conducted over a period of 5,5 yr. The NHFS was adjusted for cognitive impairment (NHFS-a) and tested. Patients who died within 30days following hip fracture surgery (early mortality group) were compared to survivors. Independent risk factors for early mortality were assessed. A new hip fracture score for frail elderly was developed: the Almelo Hip Fracture Score (AHFS). The NHFS-a and the AHFS were compared for accuracy and predictive validity. RESULTS: Sixty-four (7.5%) patients died within 30days following hip fracture surgery. The AHFS predicts the risk of early mortality better than the NHFS-a (p<0.05). Using cut-off points of AHFS ≤ 9 and AHFS ≥ 13, patients could be divided into a low, medium or high risk group. The area under the curve improved with the AHFS compared to the NHFS-a (0.82 versus 0.72). The likelihood ratio test reveals a significantly better fit of the AHFS in comparison with the NHFS-a (p<0.001). CONCLUSIONS: The AHFS can identify frail elderly at high risk of early mortality following hip fracture surgery accurately. With the AHFS, the patient can be classified into the low, medium or high risk group, which contributes to enhanced quality of care in clinical practice.

Construct validity of the Groningen Frailty Indicator established in a large sample of home-dwelling elderly persons: Evidence of stability across age and gender.

BACKGROUND: The primary objective of the present study was to evaluate the validity of the Groningen Frailty Indicator (GFI) in a sample of Dutch elderly persons participating in LifeLines, a large population-based cohort study. Additional aims were to assess differences between frail and non-frail elderly and examine which individual characteristics were associated with frailty. METHODS: By December 2012, 5712 elderly persons were enrolled in LifeLines and complied with the inclusion criteria of the present study. Mann-Whitney U or Kruskal-Wallis tests were used to assess the variability of GFI-scores among elderly subgroups that differed in demographic characteristics, morbidity, obesity, and healthcare utilization. Within subgroups Kruskal-Wallis tests were also used to examine differences in GFI-scores across age groups. Multivariate logistic regression analyses were performed to assess associations between individual characteristics and frailty. RESULTS: The GFI discriminated between subgroups: statistically significantly higher GFI-median scores (interquartile range) were found in e.g. males (1 [0-2]), the oldest old (2 [1-3]), in elderly who were single (1 [0-2]), with lower socio economic status (1 [0-3]), with increasing co-morbidity (2 [1-3]), who were obese (2 [1-3]), and used more healthcare (2 [1-4]). Overall age had an independent and statistically significant association with GFI scores. Compared with the non-frail, frail elderly persons experienced statistically significantly more chronic stress and more social/psychological related problems. In the multivariate logistic regression model, psychological morbidity had the strongest association with frailty. CONCLUSION: The present study supports the construct validity of the GFI and provides an insight in the characteristics of (non)frail community-dwelling elderly persons participating in LifeLines.

Interventions to prevent postoperative delirium in elderly cancer patients should be targeted at those undergoing nonsuperficial surgery with special attention to the cognitive impaired patients.

AIMS: The aim of this study was to determine risk factors for postoperative delirium (POD) in elderly cancer patients. METHODS: This study was an observational multicentre retrospective study performed in the University Medical Center Groningen and Medical Center Leeuwarden, the Netherlands. Patients over 65 years of age undergoing elective surgery for a solid tumour were included. The main outcome was POD. Medical records were screened for POD using a standardized instrument. The risk factors considered were: age, gender, severity of the surgical procedure, comorbidity, American Society of Anaesthesiologists (ASA) score and 15 items suggestive for frailty as measured with the Groningen Frailty Indicator (GFI). To examine an association between the risk factors and the development of POD, univariate and multivariate logistic regression analysis was performed to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: We reviewed 251 medical records. Forty-six patients developed POD (18.3%). Preoperative cognitive functioning (as measured by the item cognition of the GFI) (OR: 23.36; 95% CI: 5.33-102.36) and severity of the surgical procedure were identified as independent risk factors for POD; intermediate (OR: 15.44, 95% CI: 1.70-140.18) and major surgical procedures (OR: 45.01, 95% CI: 5.22-387.87) significantly increased the risk for POD as compared to minor surgery. CONCLUSIONS: Preoperative cognitive functioning and the severity of the surgical procedure are independent risk factors for POD in elderly undergoing elective surgery for a solid tumour.

A person-centred segmentation study in elderly care: towards efficient demand-driven care.

Providing patients with more person-centred care without increasing costs is a key challenge in healthcare. A relevant but often ignored hindrance to delivering person-centred care is that the current segmentation of the population and the associated organization of healthcare supply are based on diseases. A person-centred segmentation, i.e., based on persons' own experienced difficulties in fulfilling needs, is an elementary but often overlooked first step in developing efficient demand-driven care. This paper describes a person-centred segmentation study of elderly, a large and increasing target group confronted with heterogeneous and often interrelated difficulties in their functioning. In twenty-five diverse healthcare and welfare organizations as well as elderly associations in the Netherlands, data were collected on the difficulties in biopsychosocial functioning experienced by 2019 older adults. Data were collected between March 2010 and January 2011 and sampling took place based on their (temporarily) living conditions. Factor Mixture Model was conducted to categorize the respondents into segments with relatively similar experienced difficulties concerning their functioning. First, the analyses show that older adults can be empirically categorized into five meaningful segments: feeling vital; difficulties with psychosocial coping; physical and mobility complaints; difficulties experienced in multiple domains; and feeling extremely frail. The categorization seems robust as it was replicated in two population-based samples in the Netherlands. The segmentation's usefulness is discussed and illustrated through an evaluation of the alignment between a segment's unfulfilled biopsychosocial needs and current healthcare utilization. The set of person-centred segmentation variables provides healthcare providers the option to perform a more comprehensive first triage step than only a disease-based one. The outcomes of this first step could guide a focused and, therefore, more efficient second triage step. On a local or regional level, this person-centred segmentation provides input information to policymakers and care providers for the demand-driven allocation of resources.

The effect of music therapy compared with general recreational activities in reducing agitation in people with dementia: a randomised controlled trial.

OBJECTIVE: This study aimed to compare the effects of music therapy with general recreational day activities in reducing agitation in people with dementia, residing in nursing home facilities. METHODS: In a randomised controlled design, residents with dementia (n = 94) were allocated to either music therapy or recreational activities. Both music therapy and general activities were offered twice weekly for 4 months. Changes in agitation were measured with a modified Cohen-Mansfield Agitation Inventory (CMAI) at four intervals on each intervention day. A mixed model analysis was used to evaluate the effectiveness of music therapy, compared with general activities, on CMAI scores at 4 h after the intervention, controlled for CMAI scores at 1 h before the session and session number. RESULTS: Data were analysed for 77 residents (43 randomised to music therapy and 34 to general activities). In both groups, the intervention resulted in a decrease in agitated behaviours from 1 h before to 4 h after each session. This decrease was somewhat greater in the music therapy group than in the general activities group, but this difference was statistically not significant (F = 2.885, p = 0.090) and disappeared completely after adjustment for Global Deterioration Scale stage (F = 1.500; p = 0.222). CONCLUSIONS: Both music therapy and recreational activities lead to a short-term decrease in agitation, but there was no additional beneficial effect of music therapy over general activities. More research is required to provide insight in the effects of music therapy in reducing agitation in demented older people.

Quality of life, geriatric assessment and survival in elderly patients with non-small-cell lung cancer treated with carboplatin-gemcitabine or carboplatin-paclitaxel: NVALT-3 a phase III study.

BACKGROUND: Elderly patients with advanced non-small-cell lung cancer (NSCLC) may derive similar benefit from platinum-based chemotherapy as younger patients. Quality of life (QoL) and comprehensive geriatric assessment (CGA) is often advocated to assess benefits and risks. PATIENTS AND METHODS: A total of 181 chemotherapy-naive patients [≥70 years, performance score (PS) of 0-2] with stage III-IV NSCLC received carboplatin and gemcitabine (CG) (n = 90) or carboplatin and paclitaxel (CP) (n = 91) every 3 weeks for up to four cycles. Primary end point was change in global QoL from baseline compared with week 18. Pretreatment CGA and mini geriatric assessment during and after treatment were undertaken. A principal component (PC) analysis was carried out to determine the underlying dimensions of CGA and QoL and subsequently related to survival. RESULTS: There were no changes in QoL after treatment. The number of QoL responders (CG arm, 12%; CP arm, 5%) was not significantly different. CGA items were only associated with neuropsychiatric toxicity. Quality-adjusted survival was not different between treatment arms. The PC analysis derived from nine CGA, six QoL and one PS score indicated only one dominant dimension. This dimension was strongly prognostic, and physical and role functioning, Groningen Frailty Indicator and Geriatric Depression Scale were its largest contributors. CONCLUSIONS: Paclitaxel or gemcitabine added to carboplatin did not have a differential effect on global QoL. CGA was associated with toxic effects in a very limited manner. CGA and QoL items measure one underlying dimension, which is highly prognostic.

Recording from two neurons: second-order stimulus reconstruction from spike trains and population coding.

We study the reconstruction of visual stimuli from spike trains, representing the reconstructed stimulus by a Volterra series up to second order. We illustrate this procedure in a prominent example of spiking neurons, recording simultaneously from the two H1 neurons located in the lobula plate of the fly Chrysomya megacephala. The fly views two types of stimuli, corresponding to rotational and translational displacements. Second-order reconstructions require the manipulation of potentially very large matrices, which obstructs the use of this approach when there are many neurons. We avoid the computation and inversion of these matrices using a convenient set of basis functions to expand our variables in. This requires approximating the spike train four-point functions by combinations of two-point functions similar to relations, which would be true for gaussian stochastic processes. In our test case, this approximation does not reduce the quality of the reconstruction. The overall contribution to stimulus reconstruction of the second-order kernels, measured by the mean squared error, is only about 5% of the first-order contribution. Yet at specific stimulus-dependent instants, the addition of second-order kernels represents up to 100% improvement, but only for rotational stimuli. We present a perturbative scheme to facilitate the application of our method to weakly correlated neurons.

Extended esophagectomy in elderly patients with esophageal cancer: minor effect of age alone in determining the postoperative course and survival.

BACKGROUND: Elderly patients who undergo esophagectomy for cancer often have a high prevalence of coexisting diseases, which may adversely affect their postoperative course. We determined the relationship of advanced age (i.e., > or =70 years) with outcome and evaluated age as a selection criterion for surgery. METHODS: Between January 1991 and January 2007, we performed a curative-intent extended transthoracic esophagectomy in 234 patients with cancer of the esophagus. Patients were divided into two age groups: <70 years (group I; 170 patients) and > or =70 years (group II; 64 patients). RESULTS: Both groups were comparable regarding comorbidity (American Society of Anesthesiologists classification), and tumor and surgical characteristics. The overall in-hospital mortality rate was 6.2% (group I, 5%, vs. group II, 11%, P = 0.09). Advanced age was not a prognostic factor for developing postoperative complications (odds ratio, 1.578; 95% confidence interval, 0.857-2.904; P = 0.143). The overall number of complications was equal with 58% in group I vs. 69% in group II (P = 0.142). Moreover, the occurrence of complications in elderly patients did not influence survival (P = 0.174). Recurrences developed more in patients <70 years (58% vs. 42%, P = 0.028). The overall 5-year survival was 35%, and, when included, postoperative mortality was 33% in both groups (P = 0.676).The presence of comorbidity was an independent prognostic factor for survival (P = 0.002). CONCLUSIONS: Advanced age (> or =70 years) has minor influence on postoperative course, recurrent disease, and survival in patients who underwent an extended esophagectomy. Age alone is not a prognostic indicator for survival. We propose that a radical resection should not be withheld in elderly patients with limited frailty and comorbidity.

Music in the nursing home: hitting the right note! The provision of music to dementia patients with verbal and vocal agitation in Dutch nursing homes.

BACKGROUND: The study aims to provide insight into the type of music being offered in Dutch nursing homes to patients with both dementia and verbal and vocal agitation. It also investigates the degree to which the music offered corresponds to the musical preferences of the nursing home residents. METHOD: Using random sampling, 20 nursing homes were selected to participate in this study. Within these homes, semi-structured interviews were conducted with nursing home physicians (n = 17) and other nursing home care providers (n = 20). Each interview focused on up to three psychogeriatric residents with verbal and vocal agitation. In total, 51 residents were discussed in the interviews. RESULTS: For each resident, the frequency of music, the type of music being offered, and the degree of correspondence between the music being offered and the resident's preferences varied. In almost all cases, music was being offered in the communal living room during the mid-morning coffee and the afternoon tea, while music was only infrequently offered to residents during meals. However, this music was not tailored to the preferences of the residents. During patient-centered care activities in the early morning and before sleep, when offered, the music was generally tailored to the preferences of the resident(s). CONCLUSION: Music is frequently played in nursing homes to patients with dementia who have verbal and vocal agitation. When offered to a group of residents, the music tends not to be tailored to the preferences of the residents. However, when offered individually, musical preferences are generally taken into account.

[Questioning the ability to drive in patients with cognitive disorders]. / Twijfel aan de rijgeschiktheid bij patiënten met cognitieve stoornissen.

The relatives of an 81-year-old man questioned whether he was fit to drive, but he refused to discuss the matter. His son sent a written notice to the Dutch Driving License Centre (CBR) and the physicians were about to do so when the man fell and spent one night lying on the floor in his house. The man was hospitalised and his son took his car keys away. The approach to assessing the ability to drive in patients with cognitive disorders and dementia is a difficult matter, especially when a patient is unaware of his or her illness. At this time, licensed drivers with cognitive disorders are not obliged to report the disorder to the CBR. The CBR considers patients with dementia unfit to drive without further investigation, whereas patients with cognitive disorders must pass a driving test. This may become problematic with the early diagnosis of dementia that is preferred today. On the other hand, caregivers may have to announce a patient to the CBR when they become unfit to drive due to dementia.

[The prevalence of combined vision impairment and hearing loss: the importance of comorbidity studies]. / De prevalentie van gecombineerde visus- en gehoorbeperking: het belang van comorbiditeitsonderzoek.

Eight recent Dutch studies were analysed to determine the prevalence of dual sensory impairment: impaired vision and hearing loss. The study showed a strong increase in the prevalence of dual sensory impairment above the age of 85. In the general population, there was a 10-fold increase in prevalence between 65-80 years of age (0.5%) and 85 years and older (6%). For all age categories, the prevalence was even higher in nursing homes (7-25%) and among mentally retarded persons (6-13%). Visual impairment and hearing loss have negative effects on well-being because of the impact on resources and because of an increase in dependency and stress. Other forms of comorbidity with vision impairment or hearing loss, such as combinations with cardiovascular or psychiatric diseases, are even more important for healthcare than dual sensory impairment. The influence of comorbidity on functioning and well-being is still poorly investigated and there is a lack of empirical evidence concerning the effect of treatment in comorbid conditions.

['The old man's friend': differences between The Netherlands and the United States with regards to decision-making for the treatment of pneumonia in nursing home patients with dementia]. / 'The old man's friend': verschillen in besluitvorming over behandeling van pneumonie bij demente verpleeghuispatiënten in Nederland en de Verenigde Staten.

Lower respiratory-tract infections are a leading cause of death in frail elderly patients. A comparative study of nursing home patients with dementia in The Netherlands and the United States found a difference in attitudes regarding the treatment of pneumonia. Specifically, treatment regimens were far more aggressive in the United States than in The Netherlands for patients with severe illness. Antibiotics were withheld in 56% of these patients in The Netherlands compared with 15% in the United States. Despite the different treatment approaches, adjusted mortality rates were similar. In The Netherlands, geriatricians and family members of patients with dementia have become aware of the potentially harmful effects of the aggressive treatment approaches that are often part of professional treatment protocols, particularly in patients for whom palliative care is more appropriate.