[Decision making in frail patients with a hip fracture]. / Besluitvorming bij kwetsbare patiënt met heupfractuur.

BACKGROUND: When an older patient presents herself at the emergency department with a femur fracture different doctors are involved: the geriatrician, the orthopaedic or trauma- surgeon and the anaesthesiologist. Together they form an ad hoc team and are in charge of organising the best medical care for the patient. CASE DESCRIPTION: In this case description we present a patient with cardiovascular comorbidity and dementia. Mis-interpretation or missing information can lead to different treatment decisions and outcomes. CONCLUSION: Effective cooperation and transfer of information in physical consultation is crucial in the care of frail patients.

Differences in nutritional status between very mild Alzheimer's disease patients and healthy controls.

BACKGROUND: Studies on the systemic availability of nutrients and nutritional status in Alzheimer's disease (AD) are widely available, but the majority included patients in a moderate stage of AD. OBJECTIVE: This study compares the nutritional status between mild AD outpatients and healthy controls. METHODS: A subgroup of Dutch drug-naïve patients with mild AD (Mini-Mental State Examination (MMSE) ≥20) from the Souvenir II randomized controlled study (NTR1975) and a group of Dutch healthy controls were included. Nutritional status was assessed by measuring levels of several nutrients, conducting the Mini Nutritional Assessment (MNA®) questionnaire and through anthropometric measures. RESULTS: In total, data of 93 healthy cognitively intact controls (MMSE 29.0 [23.0-30.0]) and 79 very mild AD patients (MMSE = 25.0 [20.0-30.0]) were included. Plasma selenium (p < 0.001) and uridine (p = 0.046) levels were significantly lower in AD patients, with a similar trend for plasma vitamin D (p = 0.094) levels. In addition, the fatty acid profile in erythrocyte membranes was different between groups for several fatty acids. Mean MNA screening score was significantly lower in AD patients (p = 0.008), but not indicative of malnutrition risk. No significant differences were observed for other micronutrient or anthropometric parameters. CONCLUSION: In non-malnourished patients with very mild AD, lower levels of some micronutrients, a different fatty acid profile in erythrocyte membranes and a slightly but significantly lower MNA screening score were observed. This suggests that subtle differences in nutrient status are present already in a very early stage of AD and in the absence of protein/energy malnutrition.

Inclusion of frail elderly patients in clinical trials: solutions to the problems.

With the aging of the population, the interest in clinical trials concerning frail elderly patients has increased. Evidence-based practice for the elderly patient is difficult because elderly patients, especially the frail, are often excluded from clinical trials. To facilitate the participation of frail elderly patients in clinical trials, investigators should be more aware of possible barriers when setting up research. While conducting a trial entitled 'A randomized controlled trial of geriatric liaison intervention in frail surgical oncology patients' (LIFE) the main problem was low inclusion rates. This was due to: 1) limited physical and cognitive reserve of frail elderly patients making participation and extra visits to the hospital a burden for patients; 2) difficulty with understanding written information and information given by telephone; and 3) insufficient awareness of the study by health care professionals. To increase inclusion rates, follow-up measurements were taken at a home visit. To overcome barriers to understanding written information and information given over the phone, patients were informed face to face and questionnaires were filled in an interview format. To increase awareness, posters, pencil and sweets with the logo of the study were distributed and the study protocol was repeatedly explained to new staff. Moreover, it was checked if possible eligible patients coming to the hospital were indeed screened for participation. The mentioned measures, increased inclusion rates but also caused an increased time investment and consequently extra financial resources for staff costs.

Assessment and treatment of malnutrition in Dutch geriatric practice: consensus through a modified Delphi study.

OBJECTIVE: scientific evidence regarding the optimal management of malnutrition in geriatric patients is scarce. Our aim was to develop a consensus statement for geriatric hospital practice concerning six elements: (i) definition of malnutrition, (ii) screening and assessment, (iii) treatment and monitoring, (iv) roles and responsibilities of involved health care professionals, (v) communication and coordination of care between hospital and community health care professionals, (vi) quality indicators for malnutrition management. DESIGN: a modified Delphi study. METHODS: eleven geriatricians with special interest in malnutrition participated. In four rounds the experts rated the relevance of 204 statements, which were based on a literature review, on a five-point Likert scale. From the responses, means and 95% CIs were calculated. Consensus was defined as a lower 95% confidence limit ≥4.0. RESULTS: the panel reached consensus that malnutrition should be considered a geriatric syndrome. The nutritional status should be assessed using the Mini Nutritional Assessment combined with comprehensive geriatric assessment. Nutritional interventions should be combined with interventions targeting underlying factors. Specific goals for nutritional therapy and ways to achieve them were agreed upon. According to the experts, malnutrition is best managed by a multidisciplinary team for whom roles and responsibilities were specified. At discharge written information about the nutritional problem, treatment plan and goals should be provided to the patient, caregiver and community health care professionals. CONCLUSION: this study shows that a qualitative study based on a modified Delphi technique can result in national consensus on essential ingredients for a practical malnutrition guideline for geriatric patients.

[Health Council of the Netherlands underestimates interactions in undernutrition in the elderly]. / Gezondheidsraad miskent interacties bij ondervoeding van ouderen.

The Health Council of the Netherlands has recently published a report on undernutrition in the elderly. Undernutrition is a huge problem associated with negative health outcomes, especially in the frail elderly. Although its review of the recent literature is useful, the report does not contribute anything to clinical practice. The point is that evidence for firm conclusions is still lacking, and that most of all more research is needed to really define undernutrition and that RCTs in homogeneous groups of elderly should yield evidence on the most effective treatment strategies in the different populations in old age. This reductionist viewpoint neglects the fact that undernutrition in the elderly is a geriatric syndrome, which is mainly explained by multifactorial aetiology. Therefore, the only way forward is to study and treat undernutrition in older adults by using a broad geriatric perspective, without aiming for the holy grail of the single best evidenced definition or treatment.

Structured analyses of interventions to prevent delirium.

BACKGROUND: Delirium is one of the most serious complications in hospitalized elderly, with incidences ranging from 3-56%. The objective of this meta-analysis was two-fold, first to investigate if interventions to prevent delirium are effective and second to explore which factors increase the effectiveness of these interventions. METHODS: An electronic search was carried out on articles published between January 1979 and July 2009. Abstracts were reviewed, data were extracted and methodologic quality was assessed by two independent reviewers. Effect sizes of the interventions were expressed as ORs (odds ratios) and 95%CIs (confidence intervals). A random effect model was used to provide pooled ORs. To explore which factors increase the effectiveness of the interventions, ORs were stratified for several factors. RESULTS: Sixteen relevant studies were found. Overall the included studies showed a positive result of any intervention to prevent delirium (pooled OR: 0.64; 95%CI: 0.46-0.88). The largest effect was seen in studies on populations with an incidence of delirium above 30% in the control group (pooled OR: 0.34; 95%CI: 0.16-0.71 versus 0.76; 95%CI: 0.60-0.97). CONCLUSIONS: Interventions to prevent delirium are effective. Interventions seem to be more effective when the incidence of delirium in the population under study is above 30%. To maximize the options for a cost-effective strategy of delirium prevention it might be useful to offer an intervention to a selected population.

[Presentation of illness in the elderly: a simple explanation for a complex problem]. / Ziekte-uitingen bij ouderen: complexe problemen eenvoudig verklaard.

Illness presentation in the elderly is often complex and atypical. This may cause negative health outcomes. In the standard medical model of diagnosis, there is a 1:1 correspondence between clinical signs and symptoms and a pathological disease process. This model can be only applied to some presentations of illness in the elderly. For this reason Linda Fried, 'grande dame' of geriatric medicine in the United States, developed four complementary generic diagnostic models, taking into account social and functional aspects as well as clinical symptoms. Here we present these models for a broader audience, since not only geriatricians but all physicians are being confronted with a growing population of older patients.

Cobalamin-binding proteins in normal and cobalamin-deficient older subjects.

BACKGROUND: The causes of cobalamin (vitamin B(12)) deficiency in older people are only partly understood. We investigated the role of the cobalamin-binding proteins and tested the hypothesis that low saturated transcobalamin concentration is an early marker of cobalamin deficiency. METHODS: We measured saturated (holo) and unsaturated (apo) transcobalamin and haptocorrin concentrations in healthy middle-aged volunteers, healthy older volunteers, cobalamin-deficient older volunteers and cobalamin-deficient older patients. RESULTS: Holo and apo concentrations of transcobalamin and haptocorrin were similar in healthy middle-aged and older subjects. Holotranscobalamin concentrations were significantly decreased in cobalamin-deficient subjects but did not differ between healthy volunteers and patients. Furthermore, the relative amount of cobalamin on transcobalamin (i.e. holotranscobalamin/holotranscobalamin + holohaptocorrin) was similar in all four groups. CONCLUSIONS: Abnormalities of the cobalamin-binding proteins are not a cause of cobalamin deficiency in the aged. Plasma holotranscobalamin concentration did not differ between stages of cobalamin deficiency in older persons. Therefore, plasma holotranscobalamin is not an early marker of cobalamin deficiency in older people and has no additional value in the diagnostic work-up of reduced plasma cobalamin concentrations in older people.