[Geriatric syndromes, multimorbidity and geriatric psychiatry; an integrated perspective]. / Geriatrische syndromen, multimorbiditeit en ouderenpsychiatrie; een geïntegreerd perspectief.

BACKGROUND: The prevalence of geriatric syndromes, frailty and multimorbidity increases in older age, with a negative impact on health outcomes. Little is known on these problems in older adults with psychiatric disorders. AIM: To evaluate the prevalence of geriatric syndromes and multimorbidity in older adults with psychiatric disorders and their impact on treatment outcomes. METHOD: We conducted a pilot study and a case-control study on older adults with medically insufficiently explained symptoms, a prospective cohort study in older adults, acutely admitted to psychiatric wards and a systematic review to evaluate whether geriatric syndromes were considered in RCTs on depression treatment. RESULTS: Unexplained symptoms were often accompanied by frailty, multimorbidity and psychiatric disorders. Older adults who were acutely admitted to psychiatric wards had a high level of multimorbidity, about half of them were frail, and a third undernourished. Frailty and multimorbidity were independent predictors for not being discharged to their own home. Frailty also strongly predicted the 5-year mortality rate. Geriatric syndromes were hardly considered in study design or as secondary outcome in treatment studies on depression in older adults. CONCLUSION: Overall, geriatric problems are highly prevalent among older adults with psychiatric disorders and have a relevant prognostic impact. The complexity of older psychiatric patients is probably best addressed by interdisciplinary, integrated diagnostic and treatment trajectories.

Validation of the Care-Related Quality of Life Instrument in different study settings: findings from The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS).

PURPOSE: Validity is a contextual aspect of a scale which may differ across sample populations and study protocols. The objective of our study was to validate the Care-Related Quality of Life Instrument (CarerQol) across two different study design features, sampling framework (general population vs. different care settings) and survey mode (interview vs. written questionnaire). METHODS: Data were extracted from The Older Persons and Informal Caregivers Minimum DataSet (TOPICS-MDS, www.topics-mds.eu ), a pooled public-access data set with information on >3,000 informal caregivers throughout the Netherlands. Meta-correlations and linear mixed models between the CarerQol's seven dimensions (CarerQol-7D) and caregiver's level of happiness (CarerQol-VAS) and self-rated burden (SRB) were performed. RESULTS: The CarerQol-7D dimensions were correlated to the CarerQol-VAS and SRB in the pooled data set and the subgroups. The strength of correlations between CarerQol-7D dimensions and SRB was weaker among caregivers who were interviewed versus those who completed a written questionnaire. The directionality of associations between the CarerQol-VAS, SRB and the CarerQol-7D dimensions in the multivariate model supported the construct validity of the CarerQol in the pooled population. Significant interaction terms were observed in several dimensions of the CarerQol-7D across sampling frame and survey mode, suggesting meaningful differences in reporting levels. CONCLUSIONS: Although good scientific practice emphasises the importance of re-evaluating instrument properties in individual research studies, our findings support the validity and applicability of the CarerQol instrument in a variety of settings. Due to minor differential reporting, pooling CarerQol data collected using mixed administration modes should be interpreted with caution; for TOPICS-MDS, meta-analytic techniques may be warranted.

[Reducing fragmentation in the care of frail older people: the successful development and implementation of the Health and Welfare Information Portal]. / Het verminderen van fragmentatie in de zorg voor kwetsbare ouderen: de succesvolle ontwikkeling en implementatie van het Zorg en WelzijnsInfoPortaal.

Our fragmented health care systems are insufficiently equipped to provide frail older people with high quality of care. Therefore, we developed the Health and Welfare Information Portal (ZWIP), an e-health intervention which aims (1) to facilitate self-management by frail older people and informal caregivers and (2) to improve collaboration among professionals. The ZWIP is a personal conference table, accessible through a secure internet connection, for multidisciplinary communication and information exchange for frail older people, their informal caregivers and professionals. After development, the ZWIP was implemented in seven general practices, and this process was evaluated by means of a mixed-methods study. Eventually, 290 frail older people and 169 professionals participated in the ZWIP. Most professionals were positive about its implementation. Facilitators for the implementation were the experienced need for improvement of interprofessional collaboration and the user-friendliness of the ZWIP. Barriers were the low computer-literacy of frail older people, start-up problems, preferring personal contact, and limited use of the ZWIP by other professionals. In sum, this article describes the successful development and implementation of the ZWIP, an e-health intervention which can reduce fragmentation in the care of frail older people.

Preoperative physical performance as predictor of postoperative outcomes in patients aged 65 and older scheduled for major abdominal cancer surgery: A systematic review.

BACKGROUND: Abdominal cancer surgery is associated with considerable morbidity in older patients. Assessment of preoperative physical status is therefore essential. The aim of this review was to describe and compare the objective physical tests that are currently used in abdominal cancer surgery in the older patient population with regard to postoperative outcomes. METHODS: Medline, Embase, CINAHL and Web of Science were searched until 31 December 2020. Non-interventional cohort studies were eligible if they included patients ≥65 years undergoing abdominal cancer surgery, reported results on objective preoperative physical assessment such as Cardiopulmonary Exercise Testing (CPET), field walk tests or muscle strength, and on postoperative outcomes. RESULTS: 23 publications were included (10 CPET, 13 non-CPET including Timed Up & Go, grip strength, 6-minute walking test (6MWT) and incremental shuttle walk test (ISWT)). Meta-analysis was precluded due to heterogeneity between study cohorts, different cut-off points, and inconsistent reporting of outcomes. In CPET studies, ventilatory anaerobic threshold and minute ventilation/carbon dioxide production gradient were associated with adverse outcomes. ISWT and 6MWT predicted outcomes in two studies. Tests addressing muscle strength and function were of limited value. No study compared different physical tests. DISCUSSION: CPET has the ability to predict adverse postoperative outcomes, but it is time-consuming and requires expert assessment. ISWT or 6MWT might be a feasible alternative to estimate aerobic capacity. Muscle strength and function tests currently have limited value in risk prediction. Future research should compare the predictive value of different physical instruments with regard to postoperative outcomes in older surgical patients.

Cost-effectiveness of post-diagnosis treatment in dementia coordinated by Multidisciplinary Memory Clinics in comparison to treatment coordinated by general practitioners: an example of a pragmatic trial.

BACKGROUND: With the rising number of dementia patients with associated costs and the recognition that there is room for improvement in the provision of dementia care, the question arises on how to efficiently provide high quality dementia care. OBJECTIVE: To describe the design of a study to determine multidisciplinary memory clinics' (MMC) effectiveness and cost-effectiveness in post-diagnosis treatment and care-coordination of dementia patients and their caregivers compared to the post-diagnosis treatment and care-coordination by general practitioners (GP). Next, this article provides the theoretical background of pragmatic trials, often needed in complex interventions, with the AD- Euro study as an example of such a pragmatic approach in a clinical trial. METHOD: The study is a pragmatic multicentre, randomised clinical trial with an economic evaluation alongside, which aims to recruit 220 independently living patients with a new dementia diagnosis and their informal caregivers. After baseline measurements, patient and caregiver are allocated to the treatment arm MMC or GP and are visited for follow up measurements at 6 and 12 months. Primary outcome measures are Health Related Quality of Life of the patient as rated by the caregiver using the Quality of Life in Alzheimer's Disease instrument (Qol-AD) and self-perceived caregiving burden of the informal caregiver measured using the Sense of Competence Questionnaire (SCQ). To establish cost-effectiveness a cost-utility analysis using utilities generated by the EuroQol instrument (EQ-5D) will be conducted from a societal perspective. Analyses will be done in an intention-to-treat fashion. RESULTS: The inclusion period started in January 2008 and will commence until at least December 2008. After finalising follow up the results of the study are expected to be available halfway through 2010. DISCUSSION: The study will provide an answer to whether follow-up of dementia patients can best be done in specialised outpatient memory clinics or in primary care settings with regard to quality and costs. It will enable decision making on how to provide good and efficient health care services in dementia. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT00554047.

An in-home geriatric programme for vulnerable community-dwelling older people improves the detection of dementia in primary care.

BACKGROUND/OBJECTIVE: Dementia is under-diagnosed in primary care. This study investigated whether an in-home geriatric assessment and management programme could improve the identification of patients with dementia in primary care. METHODS: A secondary analysis was performed, using data of a randomised controlled trial that studied the effects of an in-home geriatric evaluation and management programme compared with usual care. In this trial, 151 vulnerable community-dwelling patients, aged 70 years and older, participated: 86 in the intervention group and 66 in de control group. The effect of the programme on the dementia detection rate was determined by comparing the number of new dementia diagnoses in both study arms at 6 months follow-up. RESULTS: Of all 151 participants, 38 (25%) had a registered dementia diagnosis at baseline. During follow-up, 23 of 113 patients without a registered dementia diagnosis at baseline were identified as suffering from dementia. The difference between the numbers of new dementia diagnoses in the intervention group (19 of 66 patients) and the control group (4 of 47 patients) was significant. (p = 0.02) CONCLUSION: An in-home geriatric assessment and management programme for vulnerable older patients improves the detection of dementia and can therefore contribute to overcoming of under-diagnosis of dementia.

[Dementia: growing disaster or declining epidemic?] / Dementie: groeiende ramp of afnemende epidemie?

- There is currently a lot of uncertainty about the future prevalence of dementia. Not only increasing age, but also educational level and lifestyle of the population appear to play a role.- There is little scientific and societal attention for the great uncertainty around average incidence and prevalence estimates for dementia.- When estimating the prognosis of people with dementia, the average disease course is often used as a basis, while this is not at all representative of the individual course of most patients.- The beneficial findings of recent lifestyle intervention studies ask for more targeted prevention strategies for risk groups. There is no standard preventative strategy which works equally well for everyone.- Given the large influence of dementia-related publications on the expectations of people regarding their ageing, it is important to present measures of dispersion alongside all study results.

Pseudo cluster randomization dealt with selection bias and contamination in clinical trials.

BACKGROUND AND OBJECTIVES: When contamination is present, randomization on a patient level leads to dilution of the treatment effect. The usual solution is to randomize on a cluster level, but at the cost of efficiency and more importantly, this may introduce selection bias. Furthermore, it may slow down recruitment in the clusters that are randomized to the "less interesting" treatment. We discuss an alternative randomization procedure to approach these problems. METHODS: Pseudo cluster randomization is a two-stage randomization procedure that balances between individual randomization and cluster randomization. For common scenarios, the design factors needed to calculate the appropriate sample size are tabulated. RESULTS: A pseudo cluster randomized design can reduce selection bias and contamination, while maintaining good efficiency and possibly improving enrollment. To make a well-informed choice of randomization procedure, we discuss the advantages of each method and provide a decision flow chart. CONCLUSION: When contamination is thought to be substantial in an individually randomized setting and a cluster randomized design would suffer from selection bias and/or slow recruitment, pseudo cluster randomization can be considered.

[The handling of acute life-threatening choking in geriatric and nursing home patients]. / De handelwijze bij acute levensbedreigende verstikking bij geriatrische en verpleeghuispatiënten.

It is unknown how often choking occurs in geriatric wards and in nursing homes and what the treatment and outcomes are in regular practice. A questionnaire was sent to Dutch geriatricians (N = 130), nursing home physicians (N = 130), and trainees for these disciplines (N = 215), in order to gain information about the experience, practice and competence of physicians in choking in geriatric and nursing home patients. We also analysed to what extent geriatric and nursing home wards were prepared for accurate handling of choking. The response rate was 30%. More than half of the responders had experienced an episode of food choking at least once in the past five years. The mortality rate in the reported cases was high (30%). The majority of the patients who died of choking had not received the Heimlich-manoeuvre. Physicians who had attended resuscitation training long ago felt as competent to manage a choking episode as physicians that had recently attended resuscitation training. Of all geriatric wards and nursing homes, the majority lacked a guideline on how to handle in acute food choking. Geriatric wards and nursing homes do not seem to be well prepared for acute food choking in several aspects. Despite methodological shortcomings of this study, the results underline the necessity of clarification of the terms used, and development and implementation of guidelines for this important problem.

A comparison of methods to analyse continuous data from pseudo cluster randomized trials.

A major methodological reason to use cluster randomization is to avoid the contamination that would arise in an individually randomized design. However, when patient recruitment cannot be completed before randomization of clusters, the non-blindedness of recruiters and patients may cause selection bias, while in the control clusters, it may slow recruitment due to patient or recruiter preferences for the intervention. As a compromise, pseudo cluster randomization has been proposed. Because no insight is available into the relative performance of methods to analyse data obtained from this design, we compared the type I and II error rates of mixed models, generalized estimating equations (GEE) and a paired t-test to those of the estimator originally proposed in this design. The bias in the point estimate and its standard error were also incorporated into this comparison. Furthermore, we evaluated the effect of the weighting scheme and the accuracy of the sample size formula that have been described previously. Power levels of the originally proposed estimator and the unweighted mixed models were in agreement with the sample size formula, but the power of paired t-test fell short. GEE produced too large type I errors, unless the number of clusters was large (>30-40 per arm). The use of the weighting scheme generally enhanced the power, but at the cost of increasing the type I error in mixed models and GEE. We recommend unweighted mixed models as the best compromise between feasibility and power to analyse data from a pseudo cluster randomized trial.