The implementation of integrated emotion-oriented care: did it actually change the attitude, skills and time spent of trained caregivers?

BACKGROUND: Successful implementation is a vital precondition for investigating the outcome of care innovation. This study concerned the evaluation of the implementation of integrated emotion-oriented care (IEOC) in psychogeriatric nursing home wards. The main question was whether the trained caregivers actually applied the knowledge and techniques of IEOC during their daily work. METHODS: The study was conducted within the framework of a randomized clinical trial into the effectiveness of IEOC in 16 wards. Preceding the experimental period, staff from 16 wards were educated and trained to work with a standardized care plan, resulting in a similar level of quality of care at the start of the trial. On the experimental wards IEOC was then implemented by training on the job in addition to training courses for personnel. To examine the implementation effectiveness, a self-report questionnaire, 'Emotion-oriented Skills in the Interaction with Elderly People with Dementia', was administered at baseline and after 7 months to a sample of caregivers from the experimental and the control wards. In addition, participant observation was conducted on four experimental and four control wards, and time spent by care personnel on different type of care tasks was registered. RESULTS: The implementation of IEOC resulted in increased emotion-oriented skills and more knowledge of the residents among the caregivers. Providing IEOC was not more time consuming for the caregivers than providing usual care. CONCLUSION: This study shows that the implementation of IEOC was effective. It is recommended that in intervention studies the correct application of a new intervention or care approach is examined before jumping to conclusions about the effectiveness of the intervention or care approach itself.

[ROM in adult psychiatry: an evaluation of measurement instruments]. / ROM in de volwassenenpsychiatrie: een evaluatie van meetinstrumenten.

BACKGROUND: An evaluation of the most commonly used ROM measures in Dutch psychiatry is lacking, both for severe mental illnesses and for common psychiatric disorders. AIM: To provide an overview of the characteristics and quality of outcome measures. METHOD: A literature study yielded six outcome measures. The psychometrical, clinical and practical aspects of these scales are described. RESULTS: The measures are suitable and are of adequate quality. DISCUSSION: It remains to be seen if any of the outcome measures are suitable for both serious and less serious mental illnesses. The use of a combination of a self-rating scale and an observerrating scale that measure symptoms and domains of functioning may be the most promising choice.

[Validation of two measuring instruments for routine outcome monitoring in psychiatry: the HORVAN study]. / Validering van twee meetinstrumenten voor routine outcome monitoring in de psychiatrie: de HORVAN-studie.

BACKGROUND: Transparency in psychiatry can be increased by the use of routine outcome monitoring (rom) instruments. Instruments should be easy to use and take very little time to complete; they also need to have psychometric qualities, be sensitive to change, and provide information about patients' symptoms, and about interpersonal and social functioning. AIM: To investigate to what extent the combination of Health of the Nation Outcome Scales (HoNOS) and the Outcome Questionnaire (OQ) in the Dutch situation meets the above-mentioned quality criteria and to examine how the combination relates to the Symptom CheckList (SCL-­90). METHOD: Data for 148 patients collected at three measurement moments were available for analysis. The psychometric qualities of the instruments and their sensitivity to change were checked carefully. RESULTS: The three scales showed high values for internal consistency (Cronbach's alpha). The HoNOS total score and the subscales of the OQ correlated reasonably well with the SCL­-90 total score (convergence validity). At the first measurements, patients with a comorbid diagnosis had the lowest scores (discrimination validity). The clinically significant change between T1 and T2 and between T2 and T3 was sufficiently high for all three measuring instruments. CONCLUSION: The combination of the HoNOS rating scale and the self­-report list OQ seems to be suitable for ROM in psychiatry.

[A study of job satisfaction among Dutch psychiatrists]. / Een onderzoek naar arbeidssatisfactie onder Nederlandse psychiaters.

BACKGROUND: Psychiatrists in the Netherlands seem to be experiencing more and more work stress and consequently less job satisfaction. Little research has been done in this field and the situation needs to be further investigated. AIM: To obtain insight into the degree of job satisfaction experienced by Dutch psychiatrists and into factors that influence their job satisfaction. METHOD: 2489 Dutch psychiatrists were asked to participate in a written enquiry. RESULTS: psychiatrists responded; of these, 852 responses were complete. The age, sex and years of experience of the respondents seemed to be largely representative for Dutch psychiatrists in general. Psychiatrists in the Netherlands seemed to be reasonably satisfied with their work, but they also experienced a considerable amount of work stress. In particular, it was organisationrelated work stress that reduced their job satisfaction. This pattern does not differ essentially from the pattern that exists in other countries or among representatives of other specialisms. In the Netherlands, however, the work setting is particularly significant. CONCLUSION: There seems to be a discrepancy between the relatively positive job satisfaction of Dutch psychiatrists and the high level of stress they experience as a result of working conditions. This situation is having a detrimental effect on job satisfaction. The implication is therefore that a number of managerial and policy measures need to be taken at various levels.

[Reduction in the use of seclusion: some views on the current situation]. / Terugdringen van separaties, waar staan we en hoe verder?

BACKGROUND: In 2001 quality criteria for the use of seclusion and restraint were defined for the purpose of reducing coercive measures imposed during the treatment of mental disorders. The criteria focused mainly on reducing the use of seclusion. There was broad support for the implementation of the policy. We tried to conduct a mid-term evaluation in order to find out to what extent the various policy makers involved were still in favor of the new strategy. METHOD: We interviewed 11 of the parties involved (ranging from politicians and inspectors to professionals and patients) in order to evaluate the process. RESULTS: The majority of the interviewees still agreed about the desirability and design of the process. However, there were differences in emphasis regarding the following aspects: quality control, scientific research, patient participation and pressure put on institutions. CONCLUSION: The implementation of the strategy aimed at reducing the number of seclusion is being hindered by the lack of research into the clinical practice of seclusion. If the professionals involved were to initiate such research, it would help to guarantee the quality of patient assessment and ensure the application of the new criteria.

[A randomised clinical trial on the effectiveness of a re-integration training after short-term inpatient psychotherapy]. / De effectiviteit van re-integratietraining versus boostersessies na kortdurende klinische psychotherapie: een gerandomiseerd klinisch onderzoek.

BACKGROUND: Standardised evaluation studies performed in the Netherlands in a large number of inpatient and day-treatment hospitals providing psychotherapy have shown significant symptomatic improvements in patients between the date of entry to the studies and follow-up after one year. However, the work situation of ex-patients hardly changed and a large number of patients were still receiving psychotherapy. AIM: To examine the effectiveness of a specifically designed course of re-integration training. METHOD: A group of 128 patients were assigned randomly either to a re-integration training course aimed at improved functioning at work and improved relationships, or to booster sessions. Outcome measures were symptom level, work status, absence from work, and further psychotherapy. results After two years the number of patients in paid employment remained the same (76%) in the re-integration training course and increased from 67 to 87% in the booster sessions. Attendance was significantly higher in the booster sessions than in the re-integration training. There were no differences in the other outcome measures. CONCLUSION: We conclude that re-integration training was no more effective than the booster sessions. Our hypothesis is that continuity of care (therapists plus programme) explains the favourable result of the booster sessions.

[Twenty five years of residency training in the Netherlands]. / Een kwarteeuw opleiding tot psychiater in Nederland.

Over the last 25 years in the Netherlands the residency training programme for psychiatry has been concerned primarily with teaching students to use practice guidelines, providing science education, promoting internationalisation and satisfying society's requirement for transparency. This has led to the transformation of the classical training programme with its paternalistic 'master-apprentice' relationship to a programme in which the required professional competencies are taught and assessed by supervisors who in the future will need to be explicitly qualified in particular areas. The dramatic increase in the number of women wanting to become psychiatrists has made it clear that the classical training programme puts a heavy burden on students who are struggling to combine private life with a heavy work-load and enthusiasm for their chosen subject. The compulsory personal therapy in the curriculum may be helpful in solving this problem.

[The judge follows the advice of the psychiatrist; an investigation into the jurisprudence concerning compulsory admission requests and decisions under the Dutch Act on Special Admissions to Psychiatric Hospitals (Bopz)]. / De rechter volgt de psychiater; een onderzoek naar de jurisprudentie over Bopz-aanvragen en -beslissingen in Nederland.

BACKGROUND: People are under the impression that there are differences between regions and between psychiatrists and judges in the criteria that are applied with regard to compulsory admission under the Dutch Act on Special Admissions to Psychiatric Hospitals (Bopz). AIM: To find out how the legal criteria are currently put into operation, what topics come up for discussion and what evidence the judge generally requires in order to have recourse to compulsory admission. METHOD: All judgments pronounced between 2002 and June 11 2005 and published in the journal Bopz Jurisprudence (bj) were analysed juridically. results In two-thirds of the cases the judge followed the advice of the psychiatrist and decided on compulsory admission. The required admission was refused for formal judicial reasons or because circumstances during the court hearing differed from those prevailing at the time when the medical report was drawn up. There was very little discussion about psychiatric disturbances or about the seriousness of the danger involved, but no objective criteria on this subject exist. CONCLUSIONS: The jurisprudence suggests that within the boundaries of the legally defined criteria there is still room for manoeuvre and negotiation with regard to compulsory admission applications under the Bopz Act. It is very important that the psychiatrist fully underpins his findings and draws up his application in accordance with the requirements of the Bopz Act and satisfies the judge's need for detailed information. The development and utilisation of instruments for assessing the degree of danger and the severity of the psychiatric disturbance within the framework of the Bopz could be a useful supplement to the law in its current form.

Changing patterns in emergency involuntary admissions in the Netherlands in the period 2000-2004.

BACKGROUND: In England, rates of involuntary admissions increased in subgroups of patients. It is unknown whether this is true in other European countries. AIMS: To establish whether the increase in emergency commitments was uniform across subgroups of patients and dangerousness criteria used to justify commitment in The Netherlands. METHOD: National data on all commitments in the period 2000-2004. RESULTS: Commitments increased from 40.2 to 46.5 (16%) per 100,000 inhabitants. Controlling for population changes in age and sex, relatively large increases were found in patients over 50 years (25-40% increase), in patients with dementia (59%), 'other organic mental disorders' (40%) and substance abuse (36%). 'Arousing aggression', increased most strongly as a dangerousness criterion for commitment (30%). CONCLUSION: Changing patterns of commitments in The Netherlands and England might indicate a wider European shift in diagnoses and reasons for admission of committed patients.

Trends in antidepressant use in the older population: results from the LASA-study over a period of 10 years.

BACKGROUND: In the past 15 years, antidepressant use in adults has increased, mainly due to a rise in SSRI-use. The question is if this is true for older adults as well. METHODS: Data from the Longitudinal Aging Study Amsterdam were used to investigate trends in antidepressant use from 1992 through 2002 in a population-based sample aged 65-85 years. RESULTS: Antidepressant use increased from 2% to 6%. In the group with major depressive disorder, treatment with antidepressants showed an increase from 15% to 30%. This increase was larger in the older-old than in the younger old. Also, the increase was mainly due to a rise in SSRI-use. Daily TCA-dosages often were too low; dosages of the other antidepressants seemed to be sufficient. However, rates of depression remained stable, in the treated as well as in the untreated group. LIMITATIONS: Non-response was associated with depression, the indication for prescription of antidepressants was not known, and serum concentrations of antidepressants were not available. CONCLUSIONS: Antidepressant use in older people increased over the past 15 years, mainly due to a rise in SSRI-use. Daily dosages of antidepressants had become more adequate. Still only a minority of the more severely depressed used antidepressants.

[A patient with feigned mental incompetence requiring medical treatment]. / Een patiënt die wilsonbekwaamheid simuleert en voor wie somatische behandeling is geïndiceerd.

A woman at the presumed age of 60 years was suspected of malingering cognitive impairment, due to her social circumstances (illegal residency) and was consequently unable to give permission for treatment. She was suffering from locally advanced mammary carcinoma, diagnosed according to the Breast Imaging Reporting and Data System in stage 5. In order to assess mental incompetence, an algorithm from the Royal Dutch Medical Association (KNMG) is a useful tool. The algorithm contains questions for determining whether a patient is able to make choices, if he/she understands medical information and can apply this to his/her own situation and whether he/she is able to logically consider the choice. Mental incompetence is a legally defined status - there is no straightforward relation between mental incompetence and the underlying diagnosis, in this case malingering. Since feigning mental incompetence has its own limitations, the subjective judgment of the physician is important. In the case presented, medical treatment i.e. chemotherapy was started in accordance with the Dutch Medical Treatment Contracts Act (WGBO) for a patient with cognitive impairment. Compulsory treatment was not necessary because the patient did not resist either physically or verbally. If a critical situation is to be prevented or is threatening, then there is no difference between genuine or feigned mental incompetence.

[Late-onset schizophrenia: is it a dementia nonpraecox? Review article with advice on differential diagnosis]. / Laat-ontstane schizofrenie: een dementia non-praecox?

BACKGROUND: For many years now researchers have been discussing whether late-onset schizophrenia (LOS) is in fact a separate subgroup of schizophrenia. They also want to find out whether LOS has a neurodegenerative aetiology and is a progressive illness. AIM: To obtain insight into the clinical aspects, aetiological factors and the course of late-onset schizophrenia. In addition, advice is given about better ways of diagnosing LOS in clinical practice and about differentiating LOS from dementia. METHOD: The literature was searched via Medline and the Cochrane Library on the basis of the key words '(very) late-onset schizophrenia' and 'paraphrenia' combined with 'course', 'outcome', 'cognition', 'decline', 'white matter hyperintensities', 'MRI', and 'neuropsychological', 'postmortem' and cerebrospinal fluid'. The period studied was from 1960 to November 2004. RESULTS: Clinical parameters andfunctional and structural brain research point to differences from and similarities to the early form of schizophrenia (EOS). In cases of 'very-late-onset schizophrenia-like psychosis' (VLOS) the clinical differences vis-à-vis EOS are even more marked. It is not known to what extent neurodegenerative factors play a role. There is no clear consensus about the course of (V)LOS either. CONCLUSION: In view of the aetiologial and physiopathological factors it is still not clear whether (V)LOS can be differentiated from EOS on a neurobiological basis. There is insufficient proof about the extent to which (V)LOS is a dementia nonpraecox with neurodegenerative aetiology. To achieve clear differentiation between the various forms of dementia it is essential that the clinical diagnosis of LOS is supported as strongly as possible and is evaluated continually.

[The development of psychotic symptoms in later life: late-onset schizophrenia or frontotemporal dementia? A case study]. / Het ontstaan van psychotische verschijnselen op latere leeftijd. Laat onstane schizofrenie of froontotemporale dementia?

The diagnosis of psychotic disorders that develop later in life is complicated, as can be seen from the case of a 65-year-old woman. Initially she was admitted to hospital for psychotic depression, but after some time doubts arose regarding the diagnosis. The most striking symptoms were bizarre delusions with acoustic, haptic and gustatory hallucinations. In addition, she showed behavioral and personality changes. It is difficult to establish whether a patient has late-onset schizophrenia or frontotemporal dementia. The similarities and differences between the symptoms of these two disorders are discussed and advice is given to assist with clinicians with diagnosis in the future.

Effect of the Meeting Centres Support Program on informal carers of people with dementia: results from a multi-centre study.

Because of the complex nature of the problems that carers of persons with dementia encounter, several comprehensive support programs for carers were developed in the past decade. One such program is the Meeting Centres Support Program (MCSP) that integrates different types of support for persons with dementia and their carers, which have proved to be effective in practice and/or research. Within the framework of a study into the national implementation of the MCSP, it was investigated whether the positive effects found in carers that participated in the first Amsterdam Meeting Centres, were also achieved in other regions of The Netherlands. A pre-test-post-test control group design with matched groups was applied. In total, 94 carers in the MCSP in eight meeting centres and 34 carers of dementia patients who frequented regular psychogeriatric day care (PDC) in three nursing homes were included in the study. During the study period 23 carers of the MCSP group and 21 carers of the PDC group dropped out. At baseline and after seven months indicators of burden (psychological and psychosomatic symptoms, feelings of burden and time between start of support and institutionalization of the persons with dementia) were measured, as well as potential determinants of burden (sense of competence, coping strategies, experienced support, loneliness and the emotional impact of behaviour problems). Though on a group level no effect was found, either in psychological and psychosomatic symptoms or in the determinants of burden, a subgroup of carers who felt lonely (n=22) at baseline benefited significantly more from the MCSP than from PDC in terms of psychological and psychosomatic symptoms. A majority of MCSP carers (82.1%) experienced less burden and more professional support. After seven months significantly fewer persons with dementia in the MCSP (4%) were institutionalized as compared to the patients in PDC (29%). Patients in the MCSP participated for a longer period of time before institutionalization. Although the effect on sense of competence of carers that was found in the Amsterdam study was not found in this multi-centre study, the effect on burden and delayed institutionalization of the person with dementia were confirmed. The integrated MCSP also proved more effective than PDC in decreasing psychological and psychosomatic symptoms in lonely carers. Further dissemination of the MCSP is therefore recommended.

Decision-making capacity of elderly patients assessed through the vignette method: imagination or reality?

This article evaluates whether providing hypothetical or realistic information influences the assessment of decision-making capacity in elderly patients with (and without) cognitive impairment. Decision-making capacity was assessed by means of a clinical vignette that presented a choice about whether to undergo an endoscopic procedure. The following standards of decision-making capacity were evaluated quantitatively and qualitatively: ability to evidence a choice, to understand, to reason, and to appreciate a situation. The vignette was presented to patients in either a hypothetical or real situation. In the hypothetical situation cognitively impaired patients performed significantly poorer than cognitively non-impaired patients on all abilities associated with decision-making capacity (with the exception of evidencing a choice). The realistic situation showed the same pattern among cognitively impaired and non-impaired patients in their ability to understand and in the total vignette score. Both types of patients reasoned about and appreciated the realistic situation equally well. Qualitative analysis revealed that patients gave comparable answers in both hypothetical and realistic situations. The answers were not related to standards of decision-making capacity. Moreover, personal circumstances were taken as a reference point for making a decision, regardless of the situation. We did not find any major differences between the hypothetical and realistic situation. Our findings do raise questions about the validity of hypothetical vignettes, however, especially when used with cognitively impaired persons.

Depression and generalized anxiety disorder: co-occurrence and longitudinal patterns in elderly patients.

OBJECTIVE: The authors sought to establish the natural course and risk-profile of depression, generalized anxiety disorder (GAD), and depression with co-existing GAD in later life. METHODS: A total of 2,173 community-living elderly persons were interviewed at baseline, and at a 3-year follow-up. The course of "pure" depression, "pure" GAD, and depression with coexisting GAD was studied in 258 subjects with baseline psychopathology. Authors assessed bivariate and multivariate relationships between risk factors and course types. The risk-profile for onset of pure depression, pure GAD, and the mixed condition at follow-up was studied in 1,915 subjects without baseline psychopathology. RESULTS: Remission rate at follow-up was 41% for subjects with depression-only, 48% for pure GAD, and significantly lower (27%) for depression with coexisting GAD. A pattern of temporal sequencing was established, with anxiety often progressing to depression or depression with GAD. Onset of pure depression and depression with co-existing GAD was predicted by loss events, ill health, and functional disability. Onset of pure GAD, and, more strongly, that of depression with coexisting GAD, was associated with longstanding, possibly genetic vulnerability. CONCLUSIONS: In comparison with either depression-only or anxiety-only, the co-occurrence of these represents more severe and more chronic psychopathology, associated with longstanding vulnerability. In elderly persons, GAD often progresses to depression or to the mixed condition. These findings mostly favor a dimensional, rather than a categorical, classification of anxiety and depression.

Gecombineerde ondersteuning in Ontmoetingscentra voor mensen met dementie en hun mantelzorgers vergeleken met reguliere dagbehandeling.

Background: A previous study in Amsterdam showed that combined family support in the Meeting Centres Support Programme, in which persons with dementia patients and their carers are both supported by one professional staff, is more effective in influencing behaviour problems and mood of dementia patients living in the community than non-integrated support, such as day care only. A multi-centre implementation study tests if similar effects are achieved in other regions of The Netherlands.Methods: A pretest-posttest control group design was applied. 112 dementia patients who visited psychogeriatric day care in eight community centres across the country and in three nursing homes, and their carers participated in the study. The patients in the experimental group (n=89) received support from the Meeting Centres Support Programme together with their carers, while the control group (n=23) received day care only. Behaviour problems (aggressive behaviour, inactivity, non-social behaviour) and mood (dissatisfaction, depressive behaviour) were assessed using standardized observation scales. Quality of life was assessed by interviewing the patients.Results: After 7 months the Meeting Centres Support Programme, compared to regular day care, showed a moderately positive effect on the degree of total behaviour problems (effect size=0.52), especially on inactivity (effect size=0.37) and non-social behaviour (effect size=0.60), a large effect on depressive behaviour (effect size=0.92) and a moderate effect on self-esteem (effect size=0.43).Conclusions: The Meeting Centres Support Programme proves to be more effective than regular day care in influencing behaviour problems, especially inactivity and non-social behaviour, and depressed mood. Participation in the programme also seems to have a positive effect on self-esteem, an important aspect of quality of life. These findings surpass the results of the Amsterdam study and confirm the surplus value of the Meeting Centres Support Programme as compared to regular day care for people with mild to severe dementia.

Dysthymia in later life: a study in the community.

BACKGROUND: Dysthymia (DD) may be thought of as depression associated with personality disorder, a phase in the pleomorphic natural history of unipolar depression or a result of exposure to chronic physical illness. Prevalence, clinical features, risk factors and prognosis may change with AGE. METHOD: Large (n=3056) representative sample of elderly (55-85) in the Netherlands. Two-stage screen procedure to identify elderly with DD. The Center for Epidemiologic Studies Depression scale (CES-D) was used as a screen and the Diagnostic Interview Schedule (DIS) to diagnose DD. Data on 277 depressed elderly were available to assess the 6-year prognosis of DD. RESULTS: The prevalence of DD (4.61%) was higher in women and declined with age. The symptom profiles of DD and MDD were very similar. Those with DD were very likely to have had MDD earlier in life (44% in pure DD and 80% in those with double depression). The average age at onset (31 years) was earlier than in MDD (53 years). Environmental and personal vulnerability dominated the risk-factors. The prognosis was unfavourable in most cases. LIMITATIONS: Considerable attrition and retrospective data on age at onset and previous histories of depression. CONCLUSION: Although the prevalence declines with age, DD remains common in later life. Many cases arise later than is often thought and clinical features intertwine with those of MDD in the course of life. Given the unfavourable prognosis, provision of effective treatment is warranted.

Competence to consent to treatment of geriatric patients: judgements of physicians, family members and the vignette method.

OBJECTIVE: In absence of a gold standard of methods to assess competence, three judgements of competency of geriatric patients are evaluated: the judgements of a physician, the judgement of a family member, and the judgement of an instrument. METHODS: Competence of 80 geriatric patients was judged both by a physician and a family member. Decision making capacity was assessed with a vignette. A vignette describes a treatment choice, after which the following abilities are evaluated: evidencing a choice, understanding, reasoning and appreciating a situation. Cognitive functioning was measured with the Mini-Mental State Examination. RESULTS: Most of the geriatric patients were judged competent by all three methods. Disagreement between the three judgements was found for 25 patients. Agreement about incompetence was only reached for one patient. Physicians appeared to be most lenient in their incompetency judgement: only three patients were judged incompetent. These patients scored significantly lower than competent patients on cognitive functioning, the decisional ability of understanding, and the total vignette score. Family members appeared to be most stringent in their judgement: they considered 22 patients incompetent. Incompetent patients scored significantly lower than competent patients on cognitive functioning, reasoning and the total vignette score. CONCLUSIONS: The disagreement between the judgements suggests a difference in factors given emphasis by the three methods. The finding that both the judgement of physicians and family members are associated with the assessment of the vignette, suggests that the vignette method has more than a legal theoretical base and is associated with daily life experience and knowledge as well. Physicians can be helped to assess competence by the vignette method to evaluate decisional abilities and by family members who can provide more information about patients' values.