[18 FDG PET imaging of the brain in the analysis of a dementia syndrome]. / De rol van de 18-fDG PET-scan bij de diagnose dementie.

According to current dementia guidelines from 2005 (CBO) functional brain imaging by PET-scan of the brain has no place in the analysis of a dementia syndrome. Differential diagnosis between Alzheimer disease and other causes of dementia remains important because there are differences in natural course and treatment. Here we present three patients aged 62, 71 and 68 years with dementia syndrome who were assessed at an outpatient memory clinic. After geriatric assessment and subsequent brain MRI the etiology of the dementia remained unclear. In all three patients the etiology became clear after using a 18 FDG PET-scan of the brain. We conclude that 18 FDG PET imaging of the brain has added value in the analysis of dementia syndrome with an unclear etiology after initial analysis.

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.

Single versus multicomponent intervention in frail elderly: simplicity or complexity as precondition for success?

Research on geriatric syndromes has helped to clarify risk factors and established effective intervention strategies, yet the results based on this evidence have mostly failed to translate into clinical practice. The translation of geriatric syndrome research into practice faces unique challenges, which may heighten the barriers to evidence-based implementation. The British Medical Research Council framework (MRC) for development and evaluation of complex interventions, turns out to be very valuable in developing and evaluating interventions in the complex clinical reality of geriatrics. This paper illustrates the different phases of this framework on the basis of examples from geriatric research projects in The Netherlands. The discussed barriers in complex interventions can be mapped using the different phases in the MRC-framework and thus become feasible challenges for good quality research.

Cost-effectiveness of an interdisciplinary intervention in geriatric inpatients to prevent malnutrition.

BACKGROUND: In order to reduce protein-energy malnutrition in older people during hospitalisation an early interdisciplinary intervention is needed. We developed a protocol which includes screening for malnutrition, dysphagia and dehydration on admission, followed by immediate interventions. OBJECTIVE: To assess effectiveness of the protocol on nutritional status, hospital-acquired infections and pressure sores, and to evaluate the protocol s economical feasibility. DESIGN: Prospective, controlled study. SETTING: The inpatient geriatric service of a university hospital (UMC Nijmegen) and a geriatric ward of a non-academic teaching hospital (Rijnstate Hospital, Arnhem). SUBJECTS: 298 older patients (>60 years). METHODS: One of the geriatric wards applied the protocol (N=140) while the other provided standard care (N=158). All non-terminally ill patients admitted for more than two days were included. Body mass was measured on admittance and discharge and hospital-acquired infections and pressure sores were scored and costs related to nutrition, infections and length of hospital stay were assessed. RESULTS: There was a 0.8 kg loss (SEM 0.3 kg) in average weight in the standard care group and a 0.9 kg gain (SEM 0.2 kg) in the intervention group (p<0.001). The number of hospital acquired infections was significantly lower in the intervention group (33/140 versus 58/158, p=0.01) but no significant difference in number of patients with pressure sores (23/140 versus 33/158) was found. Costs were not significantly different: 7516 versus 7908 Euro/patient for intervention versus controls, respectively. CONCLUSION: An early interdisciplinary intervention approach can be effective in reducing protein-energy malnutrition and related hospital-acquired infections and appears to be economically feasible.

[Geriatric wards in a psychiatric and a general hospital: a comparison of problems leading to admission of the patient]. / De afdeling geriatrie in een psychiatrisch en een algemeen ziekenhuis: een vergelijking van de problematiek van opgenomen patiënten.

The aim of this investigation was the comparison and description of actual problems of patients admitted to a geriatric ward of a mental hospital and patients admitted to the geriatric ward of a general hospital. The study was conducted in the geriatric unit of the Vincent van Gogh Institute of Psychiatry, in Venray and the geriatric unit in St. Maartens Gasthuis in Venio, both in the Netherlands. The design was retrospective. Data were obtained from discharge letters. The relevant diagnoses and the aetiology of the problems of all patients admitted in 1994 were categorized and compared by means of classification systems and models (medical, synergistic and causal chain model). Approximately 80 percent of the patients admitted to the geriatric unit of the mental hospital turned out to have a physical diagnosis relevant to the problems and almost every patient had a relevant psychiatric diagnosis. Life events and relationship problems played an important part. More than half of the patients admitted to the geriatric unit of the general hospital had a relevant psychiatric diagnosis and almost every patient had a physical diagnosis relevant to the problems. Mostly the aetiology of the problems of the patients of the geriatric unit of the mental hospital can be described by means of the medical model. The aetiology of the problems of the patients of the geriatric unit of the general hospital can mainly be described by the synergistic model. The causal chain model is seldom found. An event is more frequently found in the geriatric unit of the mental hospital. Often the referring Doctor could not point out adequately the underlying cause of the problems. We conclude that the problems of the patients, admitted to the geriatric unit of a mental and of a general hospital, differ substantially and in both units the problems are complex, in terms of diagnoses, aetiology and/or treatment.

[Three geriatric wards of a psychiatric hospital (GAPZ): a comparison of patient admissions]. / Drie geriatrische afdelingen van een psychiatrisch ziekenhuis (GAPZ): vergelijking van de opgenomen patiënten.

The aim of this investigation was the description and comparison of problems of patients admitted to three geriatric wards of a mental hospital. The study took place in the geriatric units at the Vincent van Gogh Institute of psychiatry in Venray, the Netherlands and was retrospective. Data obtained from discharge letters were analysed and the relevant diagnoses and the aetiology of the problems of all patients admitted in 1994 were categorised and compared. This was done bij means of classification systems and models of Fried et al. The problems of patients admitted to the geriatric unit of a mental hospital very frequently appeared to be combined problems of a psychiatric, somatic and/or social nature. In only 58% there was a simple connection between the cause(s) and the current problems. Differences between the three wards were small and non significant. In conclusion, the problems of the patients, admitted to the geriatric units of a mental hospital, did not differ significantly between the three wards. Furthermore, they are complex in terms of diagnosis, aetiology and/or treatment.

[Parkinsonism. The differential diagnosis]. / Parkinsonisme. De differentiaal-diagnose.

Considering the high prevalence of parkinsonism in people over the age of 50 and the impact of this syndrome on the patients' lives, it is important that physicians dealing with elderly people are familiar with the difficult differential diagnosis of Idiopathic Parkinson's disease (IPD). The diagnosis of IPD is entirely clinical. For a diagnosis of parkinsonism, bradykinesia must be present, and at least one of the following signs, muscular rigidity, rest tremor or postural instability. The most common cause of parkinsonism is Parkinson's disease. The two conditions that are most commonly misdiagnosed as Parkinson's disease, are essential tremor and arteriosclerotic pseudoparkinsonism. By using the proposed clinical criteria misdiagnosis can be reduced. Magnetic resonance imaging (MRI), 123I-iodobenzamide single photon emission computed tomography (IBZM-SPECT) scan and sphincter electromyogram may help in recognising alternative causes of parkinsonism.

[Favorable development of ability to function in patients during admission in a geriatric unit of a psychiatric hospital]. / Gunstige ontwikkeling van de zelfredzaamheid van patiënten tijdens opname op een geriatrische afdeling van een psychiatrisch ziekenhuis.

OBJECTIVE: To evaluate the course of the functional ability in daily living activities, mobility and faecal and urinary continence, and the interrelationship of these features of ability in patients admitted to the geriatric unit of a psychiatric hospital (GAPZ). DESIGN: Retrospective. SETTING: Geriatric unit, Vincent van Gogh Institute of Psychiatry, Venray, the Netherlands. METHOD: Analysis of data obtained from the National Register of Clinical Gerontology from SIG Care Information in Utrecht. For all patients discharged in 1992 the level of functional ability on admission and discharge was determined and compared, using 9 variables. RESULTS: During the stay all but one of the functional status variables improved significantly: washing of upper and lower body, dressing, going to the toilet, eating, urinary (in)continence and mobility (as measured by radius of action and assistance needed). Faecal incontinence did not improve. On average women functioned more independently than men; however, the improvement in functional status was equal for both sexes. There was a hierarchical decline in the event of decreased functional ability. This hierarchical relationship was more prominent at the time of discharge than at the time of admission. CONCLUSION: On average the functional status of the patients evaluated improved during their stay in the geriatric unit of the psychiatric hospital. There appears to be a hierarchy of changes in aspects of functional condition irrespective of the underlying diseases in elderly people.