Components and Outcomes in Under- and Postgraduate Medical Education to Prepare for the Delivery of Integrated Care for the Elderly: A Scoping Review.

Introduction: The ageing society requires physicians who can deliver integrated care, but it is unclear how they should be prepared for doing so. This scoping review aims to create an overview of educational programmes that prepare (future) physicians to deliver integrated care while addressing components and outcomes of the interventions. Method: We included papers from five databases that contained: (1) integrated care (2) education programme (3) medical students (4) elderly, or synonyms. We divided the WHO definition of integrated care into ten components for the concept of 'integrated care'. Data were collected with a charting template, and template analysis was used to formulate themes. Results: We found 17 educational programmes in different learning settings. All programmes addressed several components of the WHO definition. The programmes primarily focused on care for individual patients (micro-level), and the outcomes suggested that experiencing the complexity of care is key. Conclusion: This review revealed the limited evidence on educational programmes about integrated care for the elderly. Our findings suggest that educational programmes on integrated care should not be limited to the micro-level, and that students should obtain adaptive expertise by experiencing complexity. Future research should contain an explicit description and definition of integrated care.

[Death of an older patient after reactivation of latent tuberculosis]. / Wie denkt er nog aan tuberculose? Overlijden na reactivatie van latente tuberculose bij een oudere patiënt.

Latent tuberculosis has a high prevalence rate among older patients. Latent tuberculosis could be reactivated when patients are treated with immunosuppression. Therefore it is crucial to create awareness of the high prevalence of tuberculosis in the older patient. A thorough assessment of the risk of infection before starting immune modulating treatments contributes to timely recognition and treatment Our patient had an unknown history of latent tuberculosis. He was admitted to the geriatric department because of his deteriorating condition after the start of different immunosuppressing drugs for his arthritis. He developed cavitating pulmonary lesions. The PCR detected Mycobaterium tuberculosis.

Weight loss and undernutrition in community-dwelling patients with Alzheimer's dementia: From population based studies to clinical management.

Weight loss and undernutrition are commonly described in patients with Alzheimer's disease (AD) and have been associated with various adverse outcomes. Therefore, it is important to know what the best approach is to community-dwelling AD patients with a risk of developing a poor nutritional status; however, there is currently no evidence on which to base nutritional recommendations. Expert based recommendations are that the nutritional status should be part of the work-up of all AD patients. If weight loss of 5% or more has occurred in 3-6 months or if the mini-nutritional assessment (MNA) classifies a patient as undernourished, a nutritional intervention should be started. The intervention should be multifactorial and encompass treatment of the underlying proposed causes and risk factors of weight loss and undernutrition as well as improvement of the nutritional status by increasing energy and protein intake combined with daily physical activity.

Interventions to prevent postoperative delirium in elderly cancer patients should be targeted at those undergoing nonsuperficial surgery with special attention to the cognitive impaired patients.

AIMS: The aim of this study was to determine risk factors for postoperative delirium (POD) in elderly cancer patients. METHODS: This study was an observational multicentre retrospective study performed in the University Medical Center Groningen and Medical Center Leeuwarden, the Netherlands. Patients over 65 years of age undergoing elective surgery for a solid tumour were included. The main outcome was POD. Medical records were screened for POD using a standardized instrument. The risk factors considered were: age, gender, severity of the surgical procedure, comorbidity, American Society of Anaesthesiologists (ASA) score and 15 items suggestive for frailty as measured with the Groningen Frailty Indicator (GFI). To examine an association between the risk factors and the development of POD, univariate and multivariate logistic regression analysis was performed to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: We reviewed 251 medical records. Forty-six patients developed POD (18.3%). Preoperative cognitive functioning (as measured by the item cognition of the GFI) (OR: 23.36; 95% CI: 5.33-102.36) and severity of the surgical procedure were identified as independent risk factors for POD; intermediate (OR: 15.44, 95% CI: 1.70-140.18) and major surgical procedures (OR: 45.01, 95% CI: 5.22-387.87) significantly increased the risk for POD as compared to minor surgery. CONCLUSIONS: Preoperative cognitive functioning and the severity of the surgical procedure are independent risk factors for POD in elderly undergoing elective surgery for a solid tumour.

Compliance of energy-dense, small volume oral nutritional supplements in the daily clinical practice on a geriatric ward--an observational study.

INTRODUCTION: Compliance is important in optimizing the clinical effectiveness of oral nutritional supplements (ONS). Small volume, energy-dense ONS (ED-ONS; ≥ 2 kcal/ml) have been shown to improve compliance in clinical trial settings. However, data from clinical practice is still lacking. The aim of the present study was to evaluate the effect of ED-ONS on the compliance in an observational set-up to obtain data from daily clinical practice on a geriatric ward. METHODS: Geriatric inpatients, undernourished or at risk of undernutrition received two servings of either ED-ONS (125 ml, 2.4 kcal/ml: Nutridrink Compact Energy, Nutricia) or a standard ONS (S-ONS; 200 ml, 1.5 kcal/ml: Nutridrink) as part of their daily routine care. Patients were allocated to a group according to availability of beds and placement on the ward. Compliance (kcal/day and % of prescribed volume) was assessed by weighing returned bottles. Data were analyzed via Mixed Model for Repeated Measures. RESULTS: Forty-seven patients received ED-ONS, and 61 patients received S-ONS. Compliance was significantly higher with ED-ONS in geriatric inpatients compared to S-ONS ( 378 ± 14.0 kcal/day vs. 337 ± 13.6 kcal/day (mean ± SEM), p = 0.039, 63.0 ± 2.34% vs. 56.2 ± 2.26%, p = 0.039). Moreover, a trend (p=0.078) was observed towards an increasing difference in compliance over time. CONCLUSION: This study shows that compliance to ED-ONS is significantly better than to S-ONS in daily clinical practice. Although small, the difference in compliance seems to increase over time, suggesting clinical relevance with longer treatment.

The nutritional status of Dutch elderly patients with Parkinson's disease.

OBJECTIVES: To assess the prevalence of (risk of) undernutrition in Dutch elder Parkinson's disease patients as well as it's risk factors. DESIGN: Observational cross-sectional study. SETTING: An outpatient clinic at the department Neurology of Medical Centre Leeuwarden, a large teaching hospital. PARTICIPANTS: 102 outpatients with Parkinson's disease aged 65 years and older were recruited. MEASUREMENTS: Data regarding various aspects of undernutrition including socio-demographic aspect, disease characterisitics, nutritional status, appetite and overall-physical and psychological functioning were collected. RESULTS: Undernutrition was diagnosed in 2.0% and 20.5% of the patients were categorized as being at risk of undernutrition. Care dependency and appetite were the two risk factors with the highest predictive value for an unfavorable nutritional status. CONCLUSION: Of Dutch elderly patients with Parkinson's Disease 22.5% had an unfavourable nutritional status. Dependency and appetite were the two risk factors with the highest predictive value fort his outcome. Because undernutrition can be regarded as a geriatric syndrome a comprehensive nutritional assessment should be done followed by nutritional interventions next to interventions focused on the risk factors. Further studies are needed to evaluate these interventions.

Nutritional status of community-dwelling elderly with newly diagnosed Alzheimer's disease: prevalence of malnutrition and the relation of various factors to nutritional status.

OBJECTIVES: To determine the prevalence of malnutrition and its relation to various factors in community-dwelling elderly with newly diagnosed Alzheimer's disease (AD). DESIGN: Retrospective cross-sectional study. SETTING: Memory clinic in a rural part of the Netherlands. PARTICIPANTS: 312 Community-dwelling AD patients, aged 65 years or older, were included. MEASUREMENTS: At the time the diagnosis AD was made, socio-demographic characteristics and data on nutritional status (Mini Nutritional Assessment (MNA)), cognitive function (Mini Mental State Examination (MMSE), Cambridge Cognitive Examination (Camcog)), functional status (Interview for Deterioration in Daily Living Activities in Dementia (IDDD), Barthel Index (BI)) and behaviour (Revised Memory and Behaviour Problems Checklist (RMBPC)) were assessed. Characteristics of well-nourished patients (MNA score >23.5) were compared to characteristics of patients at risk of malnutrition (MNA score 17-23.5). Linear regression analysis was performed to assess the effect of various factors on nutritional status. RESULTS: The prevalence of malnutrition was 0% and 14.1% was at risk of malnutrition. AD patients at risk of malnutrition were more impaired in basic and complex daily functioning than well-nourished AD patients (median IDDD score 41.5 [25th -75th percentile 38.8-48.0] versus median IDDD score 40.0 [25th -75th percentile 37.0-43.0], p = 0.028). The degree of impairment in basic and complex daily functioning (IDDD) was independently related to nutritional status (MNA) (p = 0.001, B = -0.062). CONCLUSION: One in seven community-dwelling elderly with newly diagnosed AD is at risk of malnutrition. The degree of impairment in daily functioning is independently related to nutritional status. Therefore, assessment of the nutritional status should be included in the comprehensive assessment of AD patients. The relation between daily functioning, nutritional status and AD warrants further investigation.

Effect of long-term treatment with galantamine on weight of patients with Alzheimer's dementia.

OBJECTIVES: There is discussion about the effect of cholinesterase inhibitors (CERs) on weight of patients with Alzheimer's disease (AD). Given the adverse outcomes of weight loss in AD patients, it is important to establish the effect of CERs on weight. This study aimed tot assess the long-term effect of galantamine on weight of AD patients. DESIGN, SETTING AND PARTICIPANTS: This longitudinal study was performed at a large memory clinic in the North of the Netherlands. During the period 2002 to 2010, 303 community-dwelling AD patients, aged 65 years or older who started using a cholinesterase inhibitor (CER), were included. MEASUREMENTS: Socio-demographic characteristics and data on comorbidity, number of medications, type and dosage of CER, use of care, cognitive function, behaviour and nutritional status (weight, Body Mass Index (BMI)) were recorded at the time the diagnosis AD was made and at subsequent outpatient clinic visits. The Generalized Estimating Equations (GEE) model was used to determine the effect of galantamine of 16 mg and 24 mg on weight. The effect of galantamine in a dose of 16 and 24 mg was investigated because the other groups (rivastigmine, galantamine 8 mg) were too small to determine the effect on weight by GEE analysis. Donepezil is not available in the Netherlands. RESULTS: The median follow-up time between the moment patients started using a CER (T0) and the 1st visit was 6 months (n=300); between T0 and the 2nd visit 13 months (n=212); between T0 and the 3rd visit 25 months (n=117) and between T0 and the 4th visit 37 months (n=58). Galantamine 16 mg and 24 mg, corrected for age, gender, social status, informal care, professional care, comorbidity, number of medications, cognition, behaviour and appetite, had no effect on weight (p > 0.05). Male patients had a higher average weight compared to female patients (p=0.000, B=8.333). Patients without an informal caregiver (p=0.01, B=-3.697) or partner (p=0.042, B=-3.197) had a lower average weight compared to patients with an informal caregiver or partner. CONCLUSION: Weight loss in AD patients should not be attributed to long-term treatment with galantamine. This is in accordance with the French guideline. If AD patients are losing weight, other causes, including insufficient care, should be investigated.

[Effects of a structured medication review by geriatrician and clinical pharmacologist on appropriateness of pharmacotherapy in frail elderly inpatients]. / Interventies na een gestructureerde medicatie-analyse door klinisch geriater en ziekenhuisapotheker bij klinisch opgenomen kwetsbare oudere patiënten.

OBJECTIVE: To study the results of a structured medication review of geriatric inpatients by both geriatrician and hospital pharmacist/clinical pharmacologist. METHODS: Patients who were present at the geriatric ward were eligible for a review of their medication and medical problems using a screening form. Recommendations and questions following these forms were subsequently discussed in the gerontopharmacologic meeting ('GFO') held every two weeks. RESULTS: In a 30 month-period 44 GFO's were held during which 184 patients were discussed. A total of 206 recommendations were made and 115 questions were asked. Of the recommended interventions,134 (65%) were accepted by the geriatrician. To stop a medication (64/206), to change the dosage of a medication (60/206) and to switch to another medication (44/206) were the types of interventions most accounted for. CONCLUSION: Structured medication review led to a substantial number of medication changes in geriatric inpatients. Nearly two-thirds of the recommended interventions were accepted by the geriatricians. Seventy-two recommendations (35%) were not implemented due to logistic or patient-related reasons.

Interventies na een gestructureerde medicatie-analyse door klinisch geriater en ziekenhuisapotheker bij klinisch opgenomen kwetsbare oudere patiënten.

EFFECTS OF A STRUCTURED MEDICATION REVIEW BY GERIATRICIAN AND CLINICAL PHARMACOLOGIST ON APPROPRIATENESS OF PHARMACOTHERAPY OF FRAIL ELDERLY INPATIENTS: Objective To study the results of a structured medication review of geriatric inpatients by both geriatrician and hospital pharmacist/clinical pharmacologist. Methods Patients who were present at the geriatric ward were eligible for a review of their medication and medical problems using a screening form. Recommendations and questions following these forms were subsequently discussed in the gerontopharmacologic meeting ('GFO') held every two weeks. Results In a 30 month-period 44 GFO's were held during which 184 patients were discussed. A total of 206 recommendations were made and 115 questions were asked. Of the recommended interventions,134 (65%) were accepted by the geriatrician. To stop a medication (64/206), to change the dosage of a medication (60/206) and to switch to another medication (44/206) were the types of interventions most accounted for. Conclusion Structured medication review led to a substantial number of medication changes in geriatric inpatients. Nearly two-thirds of the recommended interventions were accepted by the geriatricians. Seventy-two recommendations (35%) were not implemented due to logistic or patient-related reasons.

Advance directives: prerequisites and usefulness.

Advance directives allow competent persons to extend their right of self-determination into the future, by recording choices that are intended to influence their future care should they become unable to make choices. They are considered tools to facilitate end-of-life decision making. Advance directives are a form of anticipatory decision-making. This article will focus on instruction directives against a certain treatment, so-called advance refusals. The most important legal requirement is the acknowledgement of patient autonomy. This condition is met in all European countries. The legal uncertainties surrounding advance refusals are focused on practical modalities rather than on the validity of the general principle. According to leading ethics the underlying moral rule of advanced directives is that all truly autonomous refusals of treatment must be respected, no matter what the consequences. Physicians find it hard to adhere to the wishes and choices of patients as expressed in directives. They find the text ambiguous. Another weakness is that directives give little information about what in the patient's view constitutes a good quality of life. Some health professionals lack the willingness to step outside their own value systems and fully embrace that of the patient. Empathic skills are required. Very few persons create an advance directive. Furthermore, of the created directives only some are accessible when patients are admitted to hospital. However, when directives are available they usually influence medical treatment decisions.

Cobalamin supplementation improves cognitive and cerebral function in older, cobalamin-deficient persons.

BACKGROUND: Mild cobalamin (Cbl) deficiency is frequently found in older persons and is associated with cognitive and cerebral abnormalities. The effects of Cbl supplementation on these abnormalities are largely unknown. METHODS: In a single-blind, placebo-controlled intervention study, 16 healthy community-dwelling elderly subjects with low plasma Cbl concentration and no cognitive impairments were studied. Subjects underwent 1 month of treatment with placebo, followed by 5 months of treatment with intramuscular injections of hydroxycobalamin. Before and after measurements of plasma cobalamin, total homocysteine (tHcy), methylmalonic acid (MMA), quantitative electroencephalograph (qEEG), and psychometric tests were taken. RESULTS: After Cbl supplementation, plasma Cbl concentrations increased, and plasma MMA and tHcy concentrations decreased. The performance on the Verbal Word Learning Test, Verbal Fluency and Similarities improved. qEEG showed more fast activity and less slow activity. Lower plasma tHcy concentrations were related to increased fast activity on qEEG on the one hand and improved performance on the Verbal Word Learning Test and Similarities on the other. Increased fast or decreased slow activity on qEEG was associated with improved performance on the Verbal Word Learning Test, Similarities and Verbal Fluency. CONCLUSIONS: Electrographic signs of improved cerebral function and improved cognitive function were found after Cbl supplementation in older subjects with low plasma Cbl concentrations who were free of significant cognitive impairment. These improvements were related to a reduction of plasma tHcy concentration.

Clinical significance of low cobalamin levels in older hospital patients.

BACKGROUND: It is still a commonly held belief that many of the frequently found low cobalamin (Cbl, vitamin B12) levels in older people do not represent deficiency and are therefore without clinical significance and should not be treated. In this study this notion will be challenged. METHODS: In this prospective observational cohort design we studied 28 patients aged 65 years and older with low plasma Cbl (< or =150 pmol/l). A number of haematological (Hb, MCV, five- and six-lobed granulocytes), metabolic (plasma levels of methylmalonic acid and homocysteine), and gastrointestinal (plasma pepsinogen A and C and protein-bound and free Cbl absorption) parameters, and the response to Cbl treatment, were measured. Cbl deficiency was considered to be present when at least one of the following three criteria was fulfilled: (1) haematological or metabolic abnormalities compatible with Cbl deficiency; (2) Cbl malabsorption or atrophic gastritis; (3) a response to Cbl supplementation. RESULTS: Haematological or metabolic abnormalities were identified in 27 patients. Atrophic gastritis and Cbl malabsorption were identified in, respectively, 15 and 23 patients. Each treated patient showed a haematological or metabolic response to Cbl supplementation. All patients were considered Cbl deficient: 18 patients (64%) fulfilled three criteria of Cbl deficiency, eight (29%) fulfilled two criteria and two (7%) fulfilled one criterion. CONCLUSIONS: According to the generally accepted and a wide variety of criteria, we found that older patients with low Cbl levels were cobalamin deficient. Therefore, these patients should receive Cbl supplementation.

Role of cobalamin intake and atrophic gastritis in mild cobalamin deficiency in older Dutch subjects.

BACKGROUND: The reason for the high prevalence of mild cobalamin (vitamin B-12) deficiency in the elderly is poorly understood. OBJECTIVE: We aimed to determine the reason for this high prevalence. DESIGN: We examined cobalamin intake, the presence and severity of atrophic gastritis, the presence of Helicobacter pylori infection, and plasma cobalamin and methylmalonic acid (MMA) concentrations in 105 healthy, free-living, older subjects aged 74-80 y. RESULTS: Mild cobalamin deficiency, ie, low to low-normal plasma cobalamin concentrations (< 260 pmol/L) and elevated plasma MMA concentrations (> 0.32 micromol/L), were found in 23.8% of subjects; 25.7% of subjects were not cobalamin deficient (plasma cobalamin > or = 260 pmol/L and plasma MMA < or = 0.32 micromol/L). Six subjects (5.8%), including 1 with mild cobalamin deficiency, had dietary cobalamin intakes below the Dutch recommended dietary intake of 2.5 microg/d. Mildly cobalamin-deficient subjects had lower total (diet plus supplements) cobalamin intakes (median: 4.9 microg/d; 25th and 75th percentiles: 3.9, 6.4) than did non-cobalamin-deficient subjects (median: 6.3 microg/d; 25th and 75th percentiles: 5.4, 7.9) (P = 0.0336), mainly because of less frequent use of cobalamin supplements (8% compared with 29.6%; chi2 = 3.9, P = 0.048). Atrophic gastritis was found in 32.4% of the total study group: mild to moderate in 19.6% and severe in 12.7%. The prevalence of severe atrophic gastritis, but not mild-to-moderate atrophic gastritis, was higher in mildly cobalamin-deficient subjects (25%) than in non-cobalamin-deficient subjects (3.7%) (chi2 = 4.6, P = 0.032). The prevalence of immunoglobulin G antibodies to H. pylori was similar in mildly cobalamin-deficient subjects (54.2%) and in non-cobalamin-deficient subjects (44.4%) (chi2 = 0.5, P = 0.5). CONCLUSIONS: The high prevalence of mild cobalamin deficiency in healthy, free-living, older Dutch subjects could be explained by inadequate cobalamin intake or severe atrophic gastritis in only 28% of the study population. Other mechanisms explaining mild cobalamin deficiency in older people must be sought.

Cerebrospinal fluid methylmalonic acid concentrations in neurological patients with low and normal serum cobalamin concentrations.

OBJECTIVE: To determine whether cerebrospinal fluid (CSF) methylmalonic acid (MMA) is increased in neurological patients with low serum cobalamin (Cbl, vitamin B12) concentrations as opposed to neurological patients with normal serum Cbl concentrations. MATERIAL AND METHODS: We measured MMA concentrations in serum and CSF of neurological patients with low serum cobalamin concentrations, but without overt cobalamin related manifestations such as anemia or combined disease of the cord, and neurological patients with normal serum cobalamin concentrations (controls). RESULTS: Serum and CSF MMA concentrations were significantly higher in patients than in controls. Serum MMA was elevated in 4 patients of whom 3 had clearly elevated CSF MMA concentrations. CONCLUSION: Strong indications for cobalamin deficiency can be found not only in serum but also in CSF of patients with seemingly asymptomatic low serum cobalamin concentrations.

[Recruitment and selection of test subjects for scientific research in geriatrics: literature review and experiences of the Nijmegen NESTOR study]. / Werving en selectie van proefpersonen voor wetenschappelijk onderzoek in de geriatrie: literatuurgegevens en ervaringen uit het Nijmeegse NESTOR-onderzoek.

The conduct of research in geriatric medicine differs from that in other medical specialties in a number of ways. In geriatric research it is almost impossible to study a large, homogeneous group of subjects, suffering solely from the problem to be studied. Moreover, measurements and questionnaires should be short, simple and not very troublesome. These differences are due to the heterogeneity of geriatric patients and the high prevalence of multimorbidity, often resulting in impaired physical, psychological and social performance. In this article a number of issues which are important for successful recruitment and selection of subjects for geriatric research are discussed. First, a review of relevant literature is given, and subsequently, experiences concerning recruitment and selection appreciated in the Nijmegen geriatric research programme' are described. This programme was part of the governmental Netherlands Programme for Research on Ageing (NESTOR). According to the literature the efficacy of recruitment may be improved by: personal contact between researcher and subject in view, introduction of the selection criteria already at the time of subjects' recruitment, a balance between research burden and profit, sufficient rewards for participation, both financially and non-financially, maximal effort in the subjects' transport, and also piloting of the recruitment procedure. In the NESTOR-studies the average number of subjects who were recruited and who completed the studies was low (23%), because a lot of the recruited subjects did not meet the selection criteria or considered participation as too troublesome. Subjects who agreed to participate showed high research compliance.

Nasal absorption of hydroxocobalamin in healthy elderly adults.

AIMS: To investigate the nasal absorption of hydroxocobalamin in 10 healthy elderly adults. METHODS: In a cross-over study, blood samples were collected before administration of the drug and after 10, 20, 30, 40, 60, 120, 180 and 240 min. The plasma cobalamin concentration was determined by competitive radioisotope binding technique. RESULTS: The maximal plasma cobalamin concentration (Cmax) after nasal administration of 750 microg hydroxocobalamin was 1900 +/- 900 pmol l(-1) (mean +/- s.d.). The maximal plasma cobalamin concentration was reached in 35 +/- 13 min (t[max]). The Cmax after nasal administration of 1500 microg hydroxocobalamin was 3500 +/- 2500 pmol l(-1) with a t(max) of 28 +/- 16 min. Both the AUC(0,240 min) and AUC(0,00) increased significantly with an increase of the dose from 750 microg to 1500 microg (P = 0.037 and P = 0.028, respectively). The nasal spray was well tolerated. No signs of irritation or local sensitivity were noted. CONCLUSIONS: The nasal absorption of hydroxocobalamin in healthy elderly adults is rapid, high and well tolerated.