Feasibility study of the Digital Patient Benefit Assessment Scale (P-BAS): A Digital Tool to Assess Individual Patient Goals.

The study objective was to assess the feasibility of the Patient Benefit Assessment Scale (P-BAS), a digital tool designed to enable older outpatients (≥70 years) to elucidate at home their individual goals regarding their current medical issue. Several digital tools are developed to assist older people in identifying their goals, thereby facilitating the process of shared decision making. However, studies on the feasibility of these digital tools, especially in older patients, are limited. Data were collected from 36 older patients. The study comprised three stages. In stage I and II, cognitive interviews were conducted to strengthen the feasibility of the P-BAS. In stage III, 80% of the patients completed the P-BAS independently at home. The cognitive interviews provided insight into patients' interpretation and individual understanding of the digital visual P-BAS and associated opportunities for improvement, which were subsequently implemented. One conclusion is that the digital visual P-BAS might be of added value for patients and contributes to the process of shared decision making, assuring that the goals of the patient will be into account in treatment options. Findings are useful for researchers interested in technological tools that contribute to shared decision making.

Diagnostic accuracy of the Dutch version of the 4AT for delirium detection in a mixed patient population and setting.

BACKGROUND: Delirium is an acute disturbance in attention, awareness and cognition. Immediate detection in older adults is recommended because delirium is associated with adverse outcomes. The 4 'A's Test (4AT) is a short screening instrument for delirium. The aim of this study is to evaluate diagnostic accuracy of the Dutch version of the screening tool 4AT for delirium detection in different settings. METHODS: Prospective observational study conducted in two hospitals in patients aged ≥ 65 years in geriatric wards and the Emergency Department (ED). Each participant underwent two assessments; the index test 4AT, followed by the reference standard for delirium performed by a geriatric care specialist. The reference standard delirium is according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria. RESULTS: A total of 71 geriatric inpatients and 49 older ED patients were included. The prevalence of delirium was 11.6% in the acute geriatric ward and 6.1% in the ED. The sensitivity and specificity of the 4AT in the acute geriatric ward were 0.88 and 0.69, respectively. In the ED, the sensitivity and specificity were 0.67 and 0.83, respectively. The area under the receiver operating characteristic curve was 0.80 for the acute geriatric ward setting and 0.74 for the ED setting. CONCLUSION: The Dutch version of the 4AT is a reliable screening tool for delirium detection in both acute geriatric wards and ED. Due to its brevity and practicality (i.e., no special training is required to administer the tool), it is useful in clinical practice.

Goal-based outcomes of hospitalisation of older adults are predicted by gender, confidence, quality of life and type of goals.

PURPOSE: Although patient-reported outcome measures (PROMs) might reflect relevant outcomes from patient perspective, they do not always reflect what the individual patient finds important. Our objectives were to assess which PROM was best suited to evaluate patient-relevant outcomes of hospitalisation and to assess which factors predicted this PROM. METHODS: A longitudinal study was conducted among hospitalised older patients. Three PROMs were compared with the anchor question 'How much have you benefited from the admission?': a general quality of life measure: EQ-5D; a measure of daily functioning: Katz-15 and a goal-based measure: achievement of self-defined goals. Predictors were examined using logistic regression analyses. RESULTS: We had 185 cases with baseline and follow-up. Accomplishment of self-defined goals showed a large correlation with the anchor question, whereas EQ-5D and Katz-15 showed no significant correlations. The final regression model had four predictors: being man, having higher confidence in goal achievement and good/excellent quality of life increased the odds for goal accomplishment, while having goals in the category alleviating complaints reduced the odds. CONCLUSION: Accomplishment of individual goals represented the benefit experienced by participants best. Subjective indicators of health and functioning are better predictors of goal accomplishment than objective ones. According to participant experience, the hospital appeared successful in managing disease-specific problems, but less successful in ameliorating complaints. Medical decision-making should not only be based on medical indicators, but the input of the patient is at least as important. Quality of life, goals and confidence should be discussed. More attention is needed for symptom experience.

The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study.

BACKGROUND: The effectiveness of interventions to improve medication safety in older inpatients is unclear, given a paucity of properly designed intervention studies applying clinically relevant endpoints such as hospital-acquired preventable Adverse Drug Events (pADEs) and unrecognized Adverse Drug Events (uADEs). Therefore, we conducted a quality improvement study and used hospital-acquired pADEs and uADEs as main outcomes to assess the effect of an intervention aimed to improve medication safety in older inpatients. METHOD: The study followed an interrupted time series design and consisted of three equally spaced sampling points during baseline and during intervention measurements. Each sampling point included between 80 to 90 patients. A total of 500 inpatients ≥65 years and admitted to internal medicine wards of three Dutch hospitals were included. An expert team retrospectively identified and assessed ADEs via a structured patient chart review. The findings from baseline measurement and meetings with the internal medicine and hospital pharmacy staff were used to design the intervention. The intervention consisted of a structured medication review by hospital pharmacists, followed by face-to-face feedback to prescribers, on average 3 days per week. RESULTS: The rate of hospital-acquired pADEs per 100 hospitalizations was reduced by 50.6% (difference 16.8, 95% confidence interval (CI): 9.0 to 24.6, P <  0.001), serious hospital-acquired pADEs by 62.7% (difference 12.8, 95% CI: 6.4 to 19.2, P <  0.001), and uADEs by 51.8% (difference 11.2, 95% CI: 4.4 to 18.0, P <  0.001). Additional analyses confirmed the robustness of the intervention effect, but residual bias cannot be excluded. CONCLUSIONS: The intervention significantly decreased the overall and serious hospital-acquired pADE occurrence in older inpatients, and significantly improved overall ADE recognition by prescribers. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number Register, trial registration number: ISRCTN64974377 , registration date (date assigned): 07/02/2011.

Head-to-head comparison of 14 prediction models for postoperative delirium in elderly non-ICU patients: an external validation study.

OBJECTIVES: Delirium is associated with increased morbidity, mortality, prolonged hospitalisation and increased healthcare costs. The number of clinical prediction models (CPM) to predict postoperative delirium has increased exponentially. Our goal is to perform a head-to-head comparison of CPMs predicting postoperative delirium in non-intensive care unit (non-ICU) elderly patients to identify the best performing models. SETTING: Single-site university hospital. DESIGN: Secondary analysis of prospective cohort study. PARTICIPANTS AND INCLUSION: CPMs published within the timeframe of 1 January 1990 to 1 May 2020 were checked for eligibility (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). For the time period of 1 January 1990 to 1 January 2017, included CPMs were identified in systematic reviews based on prespecified inclusion and exclusion criteria. An extended literature search for original studies was performed independently by two authors, including CPMs published between 1 January 2017 and 1 May 2020. External validation was performed using a surgical cohort consisting of 292 elderly non-ICU patients. PRIMARY OUTCOME MEASURES: Discrimination, calibration and clinical usefulness. RESULTS: 14 CPMs were eligible for analysis out of 366 full texts reviewed. External validation was previously published for 8/14 (57%) CPMs. C-indices ranged from 0.52 to 0.74, intercepts from -0.02 to 0.34, slopes from -0.74 to 1.96 and scaled Brier from -1.29 to 0.088. Based on predefined criteria, the two best performing models were those of Dai et al (c-index: 0.739; (95% CI: 0.664 to 0.813); intercept: -0.018; slope: 1.96; scaled Brier: 0.049) and Litaker et al (c-index: 0.706 (95% CI: 0.590 to 0.823); intercept: -0.015; slope: 0.995; scaled Brier: 0.088). For the remaining CPMs, model discrimination was considered poor with corresponding c-indices <0.70. CONCLUSION: Our head-to-head analysis identified 2 out of 14 CPMs as best-performing models with a fair discrimination and acceptable calibration. Based on our findings, these models might assist physicians in postoperative delirium risk estimation and patient selection for preventive measures.

Adaptation of the Patient Benefit Assessment Scale for Hospitalised Older Patients: development, reliability and validity of the P-BAS picture version.

BACKGROUND: The Patient Benefit Assessment Scale for Hospitalised Older Patients (P-BAS HOP) is a tool developed to both identify the priorities of the individual patient and to measure the outcomes relevant to him/her, resulting in a Patient Benefit Index (PBI), indicating how much benefit the patient had experienced from the hospitalisation. The reliability and the validity of the P-BAS HOP appeared to be not yet satisfactory and therefore the aims of this study were to adapt the P-BAS HOP and transform it into a picture version, resulting in the P-BAS-P, and to evaluate its feasibility, reliability, validity, responsiveness and interpretability. METHODS: Process of instrument development and evaluation performed among hospitalised older patients including pilot tests using Three-Step Test-Interviews (TSTI), test-retest reliability on baseline and follow-up, comparing the PBI with Intraclass Correlation Coefficient (ICC), and hypothesis testing to evaluate the construct validity. Responsiveness of individual P-BAS-P scores and the PBI with two different weighing schemes were evaluated using anchor questions. Interpretability of the PBI was evaluated with the visual anchor-based minimal important change (MIC) distribution method and computation of smallest detectable change (SDC) based on ICC. RESULTS: Fourteen hospitalised older patients participated in TSTIs at baseline and 13 at follow-up after discharge. After several adaptations, the P-BAS-P appeared feasible with good interviewer's instructions. The pictures were considered relevant and helpful by the participants. Reliability was tested with 41 participants at baseline and 50 at follow-up. ICC between PBI1 and PBI2 of baseline test and retest was 0.76, respectively 0.73. At follow-up 0.86, respectively 0.85. For the construct validity, tested in 169 participants, hypotheses regarding importance of goals were confirmed. Regarding status of goals, only the follow-up status was confirmed, baseline and change were not. The responsiveness of the individual scores and PBI were weak, resulting in poor interpretability with many misclassifications. The SDC was larger than the MIC. CONCLUSIONS: The P-BAS-P appeared to be a feasible instrument, but there were methodological barriers for the evaluation of the reliability, validity, and responsiveness. We therefore recommend further research into the P-BAS-P.

Plasma 5-HIAA activity indicative of serotonergic disturbances in cognitively impaired, elderly patients experiencing postoperative delirium.

OBJECTIVES: Delirium frequently arises in older demented and non-demented patients in postoperative, clinical settings. To date, the underlying pathophysiological mechanisms remain poorly understood. Monoamine neurotransmitter alterations have been linked to delirium and cognitive impairment. Our aim was to investigate if this holds true in cognitively normal and impaired patients experiencing delirium following hip surgery. METHODS: Monoamines and metabolites were measured in plasma samples of 181 individuals by means of reversed-phase ultra-high-performance liquid chromatography with electrochemical detection. Delirium and delirium severity were scored with the Confusion Assessment Method and Delirium Rating Scale-Revised-1998. Cognitive function was assessed using the Informant Questionnaire on Cognitive Decline and the Mini-Mental State Examination, multimorbidity with the Charlson Comorbidity Index. RESULTS: Plasma 5-hydroxyindoleacetic acid (5-HIAA), the major metabolite of serotonin (5-HT), was significantly higher in delirious and non-delirious cognitively impaired subjects as compared to control individuals without delirium and cognitive impairment (p < 0.001 and p = 0.007), which remained highly significant after excluding patients taking psychotropic medication (p < 0.0001 and p = 0.003). No significant differences were found for cognitively normal delirious patients, although serotonergic levels were numerically higher compared to control counterparts. CONCLUSIONS: Our findings indicate a general serotonergic disturbance in delirious and non-delirious postoperative patients suffering from cognitive impairment. We observed a similar, but less pronounced difference in delirious patients, which suggests serotonergic disturbances may be further aggravated by the co-occurrence of delirium and cognitive impairment.

Determinants of trajectories of fatigability and mobility among older medical patients during and after hospitalization; an explorative study.

BACKGROUND: Fatigability is an important marker of functional decline in community dwelling older people, yet its relationship with functional decline after hospitalization is unclear. The objectives of this study were to identify trajectories of fatigability and mobility over time and to examine the association between demographic and clinical characteristics and these trajectories in medical patients aged 70 years and older admitted to a Dutch tertiary care teaching hospital. METHODS: In this prospective cohort study with baseline (in-hospital), discharge, three-, and six-months post discharge follow-up measurements, fatigability was assessed by the physical subscale of the Pittsburgh Fatigability Scale (PFS). Mobility was assessed by the De Morton Mobility Index (DEMMI). Group-based trajectory modeling was used to identify joint trajectories of fatigability and mobility. Covariates included demographic (age, sex, living situation, education) and clinical characteristics (functional status, frailty status, depression, comorbidity, length of hospital stay). RESULTS: Among 44 patients, three distinct fatigability trajectories and two mobility trajectories were identified over the course from hospital admission up to six months after discharge. Subsequently, three joint trajectories were identified, including low fatigability and high mobility (11%), improving fatigability and high mobility (52%), and high fatigability and low mobility (36%). Controlling for baseline functional status, patients with a lower comorbidity score (OR: 0.27, 95%CI 0.10; 0.74) and higher frailty status (OR: 1.36, 95%CI: 1.07; 1.74) were more likely to be a member of the high fatigability and low mobility trajectories. CONCLUSIONS: From hospital admission up to six months after discharge, three distinct trajectories of fatigability and mobility were identified among older medical patients. Our results should be interpreted with caution due to the small sample size, but may inspire other researchers to determine the value of fatigability assessment in identifying older medical patients at risk for developing mobility problems.

Goals and outcomes of hospitalised older people: does the current hospital care match the needs of older people?

BACKGROUND: Due to the rising number of acutely hospitalised older people in the coming years, there is increased interest in tailoring care to the individual goals and preferences of patients in order to reach patient-centred care. AIMS: To investigate the goals of older hospitalised patients and the extent to which these goals were reached during hospitalisation. METHODS: A single-centre prospective cohort study was performed in The Netherlands between December 2017 and January 2018. Participants aged 70 years or older were included. In the first 3 days of hospitalisation, a semi-structured interview was conducted to assess the patient goals regarding the hospital admission. At 1-2 weeks after discharge, patients were asked to what extent the recent hospitalisation had contributed to reaching their goals. RESULTS: One hundred and four patients were included and follow up was completed for 86 patients. The main goals reported at hospital admission were 'remaining alive' (72.1%), 'feeling better' (71.2%) and 'improving condition' (65.4%). Hospitalisation seemed to have a positive contribution to reaching the goals 'remaining alive', 'knowing what is wrong', 'feeling better', 'reducing pain' and 'controlling disease'. Hospitalisation seemed to contribute little to reaching the goals in the categories 'enjoying life', 'independency and freedom', 'improving daily functioning', 'hobbies and work' and 'social functioning'. CONCLUSIONS: It is important for healthcare professionals to know the goals of their patients. The majority of these goals were not achieved at hospital discharge. It is important to be aware of this, so sufficient aftercare can be arranged and patients can be prepared.

Geriatric Syndromes and Incident Chronic Health Conditions Among 9094 Older Community-Dwellers: Findings from the Lifelines Cohort Study.

OBJECTIVES: To determine the association between geriatric syndromes and any specific incident chronic health conditions among older community-dwellers. DESIGN: Population-based cohort study over a median follow-up period of 43 months. SETTING AND PARTICIPANTS: Participants from the Lifelines Cohort Study aged 60 years and older without presence of the studied chronic health conditions at baseline (n = 9094). METHODS: Baseline assessment took place between November 2006 and December 2013 and included information on socioeconomic (age, sex, level of education and income), social contact, and health-related factors [eg, self-rated health, body mass index, chronic health conditions, and health behavior (alcohol consumption and smoking)]. Participants also reported the presence of geriatric syndromes (ie, included falls, incontinence, vision impairment, hearing impairment, depressive symptoms, and frailty at baseline). Three follow-up questionnaires were used to examine the incidence of any and specific chronic health conditions (ie, pulmonary and cardiovascular diseases, diabetes, cancer, and neurological diseases). Cox regression was used to analyze the longitudinal associations between geriatric syndromes and incident chronic health conditions. RESULTS: Older community-dwelling individuals with at least one geriatric syndrome (44.7%, n = 4038) had an increased risk of developing any new chronic health condition [hazard ratio (HR) 1.35; 95% confidence interval (CI) 1.21-1.51]. The association was attenuated but remained significant after adjustment for socioeconomic factors, social contact, health status, and health behavior (HR 1.27; 95% CI 1.12-1.43). Analyses for specific chronic health conditions showed that compared with older community-dwellers without geriatric syndromes, those with geriatric syndromes had an increased risk to develop a cardiovascular health condition (HR 1.42; 95% CI 1.13-1.79) or diabetes (HR 1.53; 95% CI 1.11-2.11). They had no increased risk to develop pulmonary conditions, cancer, or neurological conditions. CONCLUSION AND IMPLICATIONS: The presence of geriatric syndromes is associated with incident chronic health conditions, specifically cardiovascular conditions and diabetes. Increased awareness is needed among older people with geriatric syndromes and their physicians. Comprehensive assessments of geriatric syndromes may help to prevent or at least delay the development of chronic health conditions.

Association between dementia parental family history and mid-life modifiable risk factors for dementia: a cross-sectional study using propensity score matching within the Lifelines cohort.

OBJECTIVE: Individuals with a parental family history (PFH) of dementia have an increased risk to develop dementia, regardless of genetic risks. The aim of this study is to investigate the association between a PFH of dementia and currently known modifiable risk factors for dementia among middle-aged individuals using propensity score matching (PSM). DESIGN: A cross-sectional study. SETTING AND PARTICIPANTS: A subsample of Lifelines (35-65 years), a prospective population-based cohort study in the Netherlands was used. OUTCOME MEASURES: Fourteen modifiable risk factors for dementia and the overall Lifestyle for Brain Health (LIBRA) score, indicating someone's potential for dementia risk reduction (DRR). RESULTS: The study population included 89 869 participants of which 10 940 (12.2%) had a PFH of dementia (mean (SD) age=52.95 (7.2)) and 36 389 (40.5%) without a PFH of dementia (mean (SD) age=43.19 (5.5)). Of 42 540 participants (47.3%), PFH of dementia was imputed. After PSM, potential confounding variables were balanced between individuals with and without PFH of dementia. Individuals with a PFH of dementia had more often hypertension (OR=1.19; 95% CI 1.14 to 1.24), high cholesterol (OR=1.24; 95% CI 1.18 to 1.30), diabetes (OR=1.26; 95% CI 1.11 to 1.42), cardiovascular diseases (OR=1.49; 95% CI 1.18 to 1.88), depression (OR=1.23; 95% CI 1.08 to 1.41), obesity (OR=1.14; 95% CI 1.08 to 1.20) and overweight (OR=1.10; 95% CI 1.05 to 1.17), and were more often current smokers (OR=1.20; 95% CI 1.14 to 1.27) and ex-smokers (OR=1.21; 95% CI 1.16 to 1.27). However, they were less often low/moderate alcohol consumers (OR=0.87; 95% CI 0.83 to 0.91), excessive alcohol consumers (OR=0.93; 95% CI 0.89 to 0.98), socially inactive (OR=0.84; 95% CI 0.78 to 0.90) and physically inactive (OR=0.93; 95% CI 0.91 to 0.97). Having a PFH of dementia resulted in a higher LIBRA score (RC=0.15; 95% CI 0.11 to 0.19). CONCLUSION: We found that having a PFH of dementia was associated with several modifiable risk factors. This suggests that middle-aged individuals with a PFH of dementia are a group at risk and could benefit from DRR. Further research should explore their knowledge, beliefs and attitudes towards DRR, and whether they are willing to assess their risk and change their lifestyle to reduce dementia risk.

Reproducibility and responsiveness of the Frailty Index and Frailty Phenotype in older hospitalized patients.

BACKGROUND: There is growing interest for interventions aiming at preventing frailty progression or even to reverse frailty in older people, yet it is still unclear which frailty instrument is most appropriate for measuring change scores over time to determine the effectiveness of interventions. The aim of this prospective cohort study was to determine reproducibility and responsiveness properties of the Frailty Index (FI) and Frailty Phenotype (FP) in acutely hospitalized medical patients aged 70 years and older. METHODS: Reproducibility was assessed by Intra-Class Correlation Coefficients (ICC), standard error of measurement (SEM) and smallest detectable change (SDC); Responsiveness was assessed by the standardized response mean (SRM), and area under the receiver operating characteristic curve (AUC). RESULTS: At baseline, 243 patients were included with a median age of 76 years (range 70-98). The analytic samples included 192 and 187 patients in the three and twelve months follow-up analyses, respectively. ICC of the FI were 0.85 (95 % confidence interval [CI]: 0.76; 0.91) and 0.84 (95% CI: 0.77; 0.90), and 0.65 (95% CI: 0.49; 0.77) and 0.77 (95% CI: 0.65; 0.84) for the FP. SEM ranged from 5 to 13 %; SDC from 13 to 37 %. SRMs were good in patients with unchanged frailty status (< 0.50), and doubtful to good for deteriorated and improved patients (0.43-1.00). AUC's over three months were 0.77 (95% CI: 0.69; 0.86) and 0.71 (95% CI: 0.62; 0.79) for the FI, and 0.68 (95% CI: 0.58; 0.77) and 0.65 (95% CI: 0.55; 0.74) for the FP. Over twelve months, AUCs were 0.78 (95% CI: 0.69; 0.87) and 0.82 (95% CI: 0.73; 0.90) for the FI, and 0.78 (95% CI: 0.69; 0.87) and 0.75 (95% CI: 0.67; 0.84) for the FP. CONCLUSIONS: The Frailty Index showed better reproducibility and responsiveness properties compared to the Frailty Phenotype among acutely hospitalized older patients.

Reliability and validity of the Patient Benefit Assessment Scale for Hospitalised Older Patients (P-BAS HOP).

BACKGROUND: The Patient Benefit Assessment Scale for Hospitalised Older Patients (P-BAS HOP) is a tool which is capable of both identifying the priorities of the individual patient and measuring the outcomes relevant to him/her, resulting in a Patient Benefit Index (PBI) with range 0-3, indicating how much benefit the patient had experienced from the admission. The aim of this study was to evaluate the reliability, validity, responsiveness and interpretability of the P-BAS HOP. METHODS: A longitudinal study among hospitalised older patients with a baseline interview during hospitalisation and a follow-up by telephone 3 months after discharge. Test-retest reliability of the baseline and follow-up questionnaire were tested. Percentage of agreement, Cohen's kappa with quadratic weighting and maximum attainable kappa were calculated per item. The PBI was calculated for both test and retest of baseline and follow-up and compared with Intraclass Correlation Coefficient (ICC). Construct validity was tested by evaluating pre-defined hypotheses comparing the priority of goals with experienced symptoms or limitations at admission and the achievement of goals with progression or deterioration of other constructs. Responsiveness was evaluated by correlating the PBI with the anchor question 'How much did you benefit from the admission?'. This question was also used to evaluate the interpretability of the PBI with the visual anchor-based minimal important change distribution method. RESULTS: Reliability was tested with 53 participants at baseline and 72 at follow-up. Mean weighted kappa of the baseline items was 0.38. ICC between PBI of the test and retest was 0.77. Mean weighted kappa of the follow-up items was 0.51. ICC between PBI of the test and retest was 0.62. For the construct validity, tested in 451 participants, all baseline hypotheses were confirmed. From the follow-up hypotheses, tested in 344 participants, five of seven were confirmed. The Spearman's correlation coefficient between the PBI and the anchor question was 0.51. The optimal cut-off point was 0.7 for 'no important benefit' and 1.4 points for 'important benefit' on the PBI. CONCLUSIONS: Although the concept seems promising, the reliability and validity of the P-BAS HOP appeared to be not yet satisfactory. We therefore recommend adapting the P-BAS HOP.

Screening instruments for cognitive impairment in older patients in the Emergency Department: a systematic review and meta-analysis.

BACKGROUND: cognitive impairment is highly prevalent among older patients attending the Emergency Department (ED) and is associated with adverse outcomes. METHODS: we conducted a systematic review and meta-analysis to evaluate the diagnostic accuracy of cognitive screening instruments to rule out cognitive impairment in older patients in the ED. A comprehensive literature search was performed in MEDLINE, EMBASE, CINAHL and CENTRAL. A risk of bias assessment using QUADAS-2 was performed. RESULTS: 23 articles, examining 18 different index tests were included. Only seven index tests could be included in the meta-analysis. For ruling out cognitive impairment irrespective of aetiology, Ottawa 3 Day Year (O3DY) (pooled sensitivity 0.90; (95% CI) 0.71-0.97) had the highest sensitivity. Fourteen articles focused on screening for cognitive impairment specifically caused by delirium. For ruling out delirium, the 4 A's Test (4AT) showed highest sensitivity (pooled sensitivity 0.87, 95% confidence interval (95% CI) 0.74-0.94). CONCLUSIONS: high clinical and methodological heterogeneity was found between included studies. Therefore, it is a challenge to recommend one diagnostic test for use as a screening instrument for cognitive impairment in the ED. The 4AT and O3DY seem most promising for ruling out cognitive impairment in older patients attending the ED.The review protocol was registered in PROSPERO (CRD42018082509).

COVID-19: Technology-Supported Remote Assessment of Pediatric Asthma at Home.

The COVID-19 crisis has pressured hospital-based care for children with high-risk asthma as they have become deprived of regular clinical evaluations. However, COVID-19 also provided important lessons about implementing novel directions for care. Personalized eHealth technology, tailored to the individual and the healthcare system, could substitute elements of hospital care and facilitate early and appropriate medical anticipation in response to imminent loss of control. This perspective article discusses new approaches to the clinical, organizational, and scientific aspects of the use of eHealth technology in pediatric asthma care in times of COVID-19, as illustrated by a case report of an acute asthma exacerbation possibly caused by COVID-19 infection.

Delirium, functional decline and quality of life after transcatheter aortic valve implantation: An explorative study.

AIM: Transcatheter aortic valve implantation (TAVI) has become an important treatment option for older patients with severe aortic stenosis. However, not all patients benefit from this procedure in terms of functional outcome and quality of life. This complicates patient selection and shared decision-making. Postoperative delirium might negatively affect patient outcomes after TAVI. We therefore studied the potential relationship between postoperative delirium and functional outcome, and how this impacts quality of life after TAVI. METHODS: This was a prospective cohort study of 91 consecutive patients undergoing TAVI between 2015 and 2017 at an academic medical center. All patients underwent a Comprehensive Geriatric Assessment before TAVI. Delirium symptoms were assessed daily during hospitalization. Follow up was carried out between 6 and 12 months postprocedure. The primary outcome was functional decline or death at follow up. Secondarily, we measured quality of life at follow up. RESULTS: The incidence of postoperative delirium was 15.4%. In total, 38.5% of patients experienced functional decline, and 11.0% died during a median follow-up period of 7 months. Delirium resulted in a fourfold increased odds of the combined outcome of functional decline or death. Quality of life was lower in patients that experienced this outcome. CONCLUSION: In a cohort of TAVI patients, functional decline or death was a frequent outcome in the first year postprocedure. Postoperative delirium increased the odds for this outcome substantially. This suggests that delirium risk should be an important factor to consider in shared decision-making for TAVI patients. Geriatr Gerontol Int 2020; 20: 1202-1207.

Uptake and effectiveness of a tailor-made online lifestyle programme targeting modifiable risk factors for dementia among middle-aged descendants of people with recently diagnosed dementia: study protocol of a cluster randomised controlled trial (Demin study).

INTRODUCTION: Descendants of patients with dementia have a higher risk to develop dementia. This study aims to investigate the uptake and effectiveness of an online tailor-made lifestyle programme for dementia risk reduction (DRR) among middle-aged descendants of people with recently diagnosed late-onset dementia. METHODS AND ANALYSIS: Demin is a cluster randomised controlled trial, aiming to include 21 memory clinics of which 13 will be randomly allocated to the passive (poster and flyer in a waiting room) and 8 to the active recruitment strategy (additional personal invitation by members of the team of the memory clinic). We aim to recruit 378 participants (40-60 years) with a parent who is recently diagnosed with Alzheimer's disease or vascular dementia at one of the participating memory clinics. All participants receive a dementia risk assessment (online questionnaire, physical examination and blood sample) and subsequently an online tailor-made lifestyle advice regarding protective (Mediterranean diet, low/moderate alcohol consumption and high cognitive activity) and risk factors (physical inactivity, smoking, loneliness, cardiovascular diseases (CVD), hypertension, high cholesterol, diabetes, obesity, renal dysfunction and depression) for dementia. The primary outcome is the difference in uptake between the two recruitment strategies. Secondary outcomes are change(s) in (1) the Lifestyle for Brain Health score, (2) individual health behaviours, (3) health beliefs and attitudes towards DRR and (4) compliance to the tailor-made lifestyle advice. Outcomes will be measured at 3, 6, 9 and 12 months after baseline. The effectiveness of this online tailor-made lifestyle programme will be evaluated by comparing Demin participants to a matched control group (lifelines cohort). ETHICS AND DISSEMINATION: This study has been approved by the Dutch Ministry of Health, Welfare and Sport according to the Population Screening Act. All participants have to give online informed consent using SMS-tan (transaction authentication number delivered via text message). Findings will be disseminated through peer-reviewed journals and (inter)national conferences. TRIAL REGISTRATION NUMBER: NTR7434.

The influence of a serious game's narrative on students' attitudes and learning experiences regarding delirium: an interview study.

BACKGROUND: Delirium is a neuropsychiatric syndrome that affects patients' attention and awareness as a result of a physical condition. In recent years, persistent gaps in delirium education have led to suboptimal delirium care. Still, little is known about what are the most important aspects of effective delirium education. Serious games are both entertainment and an interactive, safe learning environment where players can experiment and create new knowledge. They have the potential to contribute to improved delirium education. We used a video-based serious games' narrative to explore aspects essential to enhance students' attitudes and learning experiences regarding delirium. METHODS: We created a semi-structured interview guide and interviewed seven nursing and nine medical students about their attitudes and learning experiences, after they had played the game. A qualitative descriptive design and inductive content analysis with constant comparison were used. RESULTS: The patient's and nurse's perspective, interactivity to experiment, realistic views on care options, and feedback on care actions were important for enhancing students' attitudes and learning experiences regarding delirium. Students felt these aspects encouraged them to get actively involved in and experiment with the study material, which in turn led to enhanced reflection on delirium care and education. Our findings highlight the importance of a more patient-oriented focus to delirium education to drive attitudinal change. Students' learning experiences were further enhanced through their affective responses provoked by the perspectives, interactivity, realism, and feedback. CONCLUSIONS: Students considered the characters' perspectives, interactivity, realism, and feedback important aspects of the game to enhance their attitudes towards delirious patients and enrich their learning experiences. A patient-oriented narrative provides a clinically relevant experience in which reflection plays an important role. The serious game also serves as medium to actively experiment with care solutions to create better understanding of how healthcare professionals can influence a delirious patient's experience.

Reasons to Engage in and Learning Experiences From Different Play Strategies in a Web-Based Serious Game on Delirium for Medical Students: Mixed Methods Design.

BACKGROUND: Although many studies have recently been published on the value of serious games for medical education, little attention has been given to the role of dark play (choosing unacceptable actions in games). OBJECTIVE: This study aimed to investigate potential differences in the characteristics of medical students who have the opportunity to choose normal or dark play in a serious game. This study also aimed to compare their reasons for choosing a play strategy and their perceptions of what they learned from their game play. METHODS: We asked undergraduate medical students to play a serious game in which they had to take care of a patient with delirium (The Delirium Experience). After getting acquainted with the game, students could opt for normal or dark play. Student characteristics (age, gender, experience with caring for older or delirious patients, and number of completed clerkships) were collected, and the Delirium Attitude Scale and Learning Motivation and Engagement Questionnaire were administered. Reasons for choosing normal or dark play were evaluated with an open-ended question. Information on lessons they had learned from the game was collected using an open-ended question and self-reported knowledge on delirium. RESULTS: This study had 160 participants (89 normal play, 71 dark play). Male students (26/160, 56.5%) chose dark play significantly more often than female students (45/160, 39.5%; P=.049). We did not find significant differences in student characteristics or measurement outcomes between play strategies. Participants' main reason for choosing normal play was to learn how to provide care to delirious patients, and the main reason for dark play was to gain insight into what a delirious patient has to endure during delirious episodes. All participants learned what to do when taking care of a delirious patient and gained insight into how a patient experiences delirium. We found no differences in self-reported knowledge. CONCLUSIONS: When medical students have the opportunity to choose dark play in a serious game, half of them will probably choose this play strategy. Male students will more likely opt for dark play than female students. Choice of play strategy is not affected by any other student characteristic or measurement outcome. All students learned the same lessons from playing the game, irrespective of their learning strategy.

Translation and validation of the Dutch Pittsburgh Fatigability Scale for older adults.

BACKGROUND: The original Pittsburgh Fatigability Scale (PFS) was developed to assess perceived fatigability in older adults. The objective of this study was to translate the PFS into Dutch and investigate its validity and reliability among hospitalized older adults aged ≥70 years. METHODS: The PFS was translated into Dutch and pretested for comprehensibility by the Three-Step Test Interview method. The factor structure underlying the final version was evaluated by confirmatory factor analysis (CFA) and exploratory factor analyses (EFA). Internal consistency of the identified subscales was evaluated by Cronbach's alpha. Construct validity was evaluated by hypothesis testing. Test-retest reliability was evaluated using intraclass correlation coefficients (ICC) and Bland Altman plots. RESULTS: The validation sample included 233 patients. CFA of the original factor structure resulted in poor model fit in our Dutch sample. EFA of PFS physical and mental subscales resulted in a two-factor solution underlying the data with good internal consistency of the identified subscales (Cronbach's alpha: 0.80-0.92). Five out of six hypotheses were confirmed, indicating good construct validity. Retest assessments were performed among 50 patients and showed good reliability for both the physical (ICC: 0.80, 95%CI: 0.68; 0.88) and mental subscale (ICC: 0.81, 95%CI: 0.68; 0.89). CONCLUSION: The Dutch PFS is a valid and reliable instrument to assess fatigability in older hospitalized patients.