Samenwerking tussen woonzorgcentra en voorzieningen voor personen met verstandelijke beperkingen

Considering the increasing life expectancy of people with intellectual disabilities (ID), the importance of cooperation between services for people with ID and elderly care services has been stressed in Flanders and the Netherlands, as well as internationally. However, the prevalence, intensity and content of such a cooperation are yet unknown. In order to gain information to address this issue, an online-survey was delivered to directors of all nursing homes in Flanders (n = 781). 229 surveys were completed.In more than 75% of the nursing homes, people with ID were among the residents over the past decade. However, at the same time a lack of expertise has been identified as a barrier to provide them optimal care and support. Hence, the respondents point out that a cooperation with ID care services could be beneficial. Nevertheless, those partnerships only arose in a quarter of the nursing homes so far, primarily for the purpose of exchange of expertise. Intersectoral multidisciplinary consultations and intersectoral care team consultations have been taking place as well, be it mainly in the context of a persons’ transition from an ID care service to a nursing home. Until now, radical cooperations which involve an exchange of staff, seem to be rather rare.     

Een multidisciplinaire benadering voor een adequate aanpak van probleemgedrag bij dementie

Problem behaviours in one form or another are very common in nursing home residents with dementia. In order to manage these challenging behaviours pharmacological and psychosocial interventions are necessary. Psychosocial interventions have gained a more central role due to negative affects of pharmacological treatment. This case study describes the multidisciplinary approach of problem behaviour in an 85 year old nursing home patient with dementia. Those involved in caring for this patient initiated changes that led to a more adequate treatment and ultimately a decrease in the problematic behaviour.     

Een kwalitatieve exploratie van het chronisch gebruik van psychofarmaca in woonzorgcentra

Background

Although guidelines put forward non-pharmacological therapies and advise against the chronic use of psychotropic drugs, these are still being prescribed regularly in Belgian nursing homes.

Goal

To explore the reasons for initiation, continuation and cessation of psychotropic drug treatment of elderly with dementia and behavioral problems, residing in the nursing home.

Method

Twenty-seven interviews from an earlier project were used, in which a semi-structured interview was conducted with the nursing staff, the physicians and the caretakers of eleven randomly selected residents from three nursing homes. A qualitative analysis was performed by three independent researchers according to ‘The Qualitative Analysis Guide of Leuven (QUAGOL)’. A first analysis focused on the process of initiation, continuation and cessation of medication. A second analysis compared the different participants of each interview and looked for similarities and differences.

Results

Seventeen codes were developed for four themes: (1) To initiate, to continue or to cease?; (2) Behavior; (3) Therapy; and (4) Alternatives. The reasons for initiating psychotropic drugs were reducing disruptive behavior and improving the quality of life of the resident. A comparison between the interviewed showed that psychotropic drugs were initiated at the request of the nursing staff. Neither doctors nor nurses considered the monitoring of the drug therapy their task, and tended to pass on this responsibility. Once psychotropic drugs were started, the treatment was chronic but remained part of a dynamic process in which a balance was sought between benefits and adverse effects. More insights into the behavior of the resident led to a better treatment of the behavioral problems.

Conclusion

Nurses play an important role in the initiation and continuation of psychotropic drugs. Physicians should take a more active role in the process of indication and monitoring of psychopharmaceuticals. Discontinuation of psychotropic drugs and the use of non-pharmacological alternatives are important bottlenecks in nursing homes. Education and training, updated practice guidelines, appropriate research, professionalization and management elements can, in a complex interaction, change this situation for the better.

     

Measuring discomfort in patients with dementia. Validity of a Dutch version of the Discomfort Scale--dementia of Alzheimer type (DS-DAT)

The Discomfort Scale--Dementia of Alzheimer Type (DS-DAT) is an instrument to assess discomfort in patients with severe dementia by observing patients' behaviour during five minutes. Trained nursing home physicians collected data of 662 pneumonia patients with dementia. The data were used to test the validity of a Dutch translation of the DS-DAT as a measure of discomfort. Internal consistency of the nine-item instrument was favourable (Cronbach's alpha ranged between 0.82 and 0.84 for different times during and following the pneumonia), and factor analyses indicated measurement of a single concept. Furthermore, as hypothesised, discomfort appeared moderately associated with acute illness. Nursing home physicians' assessment of DS-DAT scores therefore appeared a suitable method to assess discomfort in severely demented psychogeriatric nursing home patients for research purposes. For use in individual patients, results are probably too strongly affected by the chosen time fluctuations of assessment. For this purpose, the current rater assessment instructions should be adapted and tested.     

De <Emphasis Type="Italic">BPSD-DS</Emphasis> evaluatieschaal voor dementiegerelateerde gedragsveranderingen bij mensen met downsyndroom

Behavioral and psychological symptoms of dementia (BPSD) have not been comprehensively studied in people with Down syndrome, despite their high risk on dementia. A novel evaluation scale was developed to identify the nature, frequency and severity of behavioral changes (83 behavioral items in 12 clinically defined sections). Central aim was to identify items that change in relation to the dementia status. Structured interviews were conducted with informants of people with Down syndrome without dementia (DS, N?=?149), with questionable dementia (DS?+?TD, N?=?65) and with diagnosed dementia (DS?+?AD, N?=?67). Group comparisons showed a pronounced increase in frequency and severity of items about anxiety, sleep disturbances, agitation & stereotypical behavior, aggression, apathy, depressive symptoms, and, eating/drinking behavior. The proportion of individuals presenting an increase was highest in the DS?+?AD group and lowest in the DS group. Interestingly, among DS?+?TD individuals, a substantial proportion already presented increased anxiety, sleep disturbances, apathy and depressive symptoms, suggesting that these changes may be early alarm signals of dementia. The scale may contribute to a better understanding of the changes, adapting daily care/support, and providing suitable therapies to people with Down syndrome. The scale needs to be optimized based on the results and experiences. The applicability, reliability and validity require further study.     

Fysieke fixatie en slimme technologie in Vlaamse woonzorgcentra: Resultaten van een surveybevraging bij zorg- en beleidspersoneel over visie en gebruik

Aim

The STAFF-project investigates in what way ‘smart technology’ can offer an alternative for physical restraints in nursing homes. A survey is realized aimed at gaining more insight into the vision on and the use of physical restraints and ‘smart technology’.

Method

Two partly overlapping structured questionnaires were developed and sent to nursing home staff in Flanders (Belgium). One hundred fifty six administrators (managers or assistant-managers) and 238 caregiving staff (nurses, nursing aids, paramedical staff and other) completed the online questionnaire.

Results

In general there is a low acceptability of physical restraint use, however, a more nuanced picture of acceptability is present depending on the specific motivation for using physical restraints and on the specific means of physical restraints. About half of the administrators say they use smart technology in the nursing home. The two main reasons for not applying (yet) smart technology are ‘too high price for smart technology’ and ‘inadequate infrastructure of the nursing home’. All respondents underscore the importance of multiple strategies to diminish the use of physical restraints in nursing homes.

Conclusion

Physical restraint use is a complex theme and needs a nuanced analysis and management. This study shows that there is still room for improvement in diminishing the use of physical restraints and that nursing homes in Flanders are open to use smart technology.

     

Mediatietherapie bij ouderen met een persoonlijkheidsstoornis: Een verpleegkundige benadering

Behavioural counselling by nurses can enhance quality of life in elderly with a personality disorder. Although nurses have a crucial role in day-to-day treatment, there is a lack of evidence-based approaches. Based on the cognitive therapy, the treatment protocol Cognitive Model for Behavioural Interventions (CoMBI) provides an alternative nursing approach for personality disorders.     

Pilot study naar het persoonsgericht gebruik van foto’s in de communicatie met mensen met dementie

Social contact is important for the wellbeing of people. Dementia can complicate social interaction. In two randomized controlled pilot studies, it was investigated whether viewing different types of images together affects the mood and social interaction of people with moderately severe to severe Alzheimer’s dementia residing in nursing homes. At the first intervention participants in the experimental group (n?=?10) were shown portraits with positive facial expressions, and the participants in the control group (n?=?10) were shown portraits with a neutral facial expression. During the second intervention, the experimental group (n?=?10) were shown personalized photos and the control group (n?=?10) non-personalized photos. There were no statistically significant differences in mood and the degree of social interaction between the groups. However, calculation of the effect sizes showed that there was a tendency for more positive behavior in viewing neutral portraits and that personalized images had a more positive impact on social interaction, negative behavior, speech and mood.     

Interventies bij het signaleren van pijn bij verpleeghuisbewoners met dementie: de pilot implementatie van een pijnbeoordelingsinstrument (PACSLAC-D)

Pain occurs regularly among nursing home residents with dementia. There are indications that appliance of structural pain assessment can contribute to the adequate diagnosis of pain. The aim of this study is to gain insight into applied interventions after diagnosing pain with an observational pain scale (PACSLAC-D) among nursing home resident with dementia. During a six week period pain was measured twice a week, among 22 residents of a psychogeriatric nursing home ward, using the PACSLAC-D. Interventions undertaken as a result of a pain score were inventoried on a data-sheet. After the third and sixth week implementation of pain assessment was evaluated. In total 264 pain assessments using the PACSLAC-D were conducted. Of all scheduled standardized measurements 90% was completed. Sixty observations resulted in a pain score. Completed datasheets (N=39) showed that a pain score often (N=17) did not result in any intervention. The majority of interventions that were undertaken consisted of a non pharmacological approach (N=19). Evaluation meetings indicated that the PACSLAC-D was considered useful, though the chosen procedure of standardized measurements twice a week was not yet ideal. This study demonstrates that although there was a high compliance rate, pain relieving interventions were not frequently applied.     

Kwaliteit van leven bij dementie

Different definitions of quality of life (QOL) are found in the literature. This raised the question which domains are viewed as really important by persons with dementia. In an explorative study the opinions of persons with dementia (community-dwelling and living in nursing homes), were compared to those of professional carers and instruments for QOL in dementia. Data were gathered through interviews, focus groups and literature study. Most QOL-domains mentioned as important by persons with dementia were also acknowledged by carers and in measurement instruments. Some domains, however, were not mentioned by the carers (‘sense of aesthetics’, ‘financial situation’, ‘being useful’ and ‘spirituality’), or not selected in the measuring instruments (‘security and privacy’, ‘self-determination and freedom’, ‘being useful’ and ‘spirituality’). This indicates differences in perspectives on quality of life between persons with dementia, professional caregivers and researchers. Subsequently it was studied to what degree professionals focus on the QoL-domains that persons with dementia consider essential. Caregivers working on 29 units and 3 day care facilities of 13 nursing homes and in 12 meeting centers filled out a questionnaire (N=374). They reported to focus at least to some degree on most domains considered important by persons with dementia. However, little attention was paid to the domains ‘financial situation’ and ‘being useful’. Professionals offering daytime activities focused more than 24-hour care staff on ‘attachment’, ‘enjoyment of activities’, ‘sense of aesthetics’, and ‘being useful’ This article is a translation and merging of 1) Dröes et al. Quality of life in dementia in perspective; an explorative study of variations in opinions among people with dementia and their professional caregivers, and in literature. Dementia: The International Journal 2006; 5 (4): 533–558, and 2) Gerritsen et al. Differences in perspective: do professional caregivers focus on the Quality of life domains that are important for people with dementia? American Journal of Alzheimer’s Disease and Other Dementias 2007; 22:176–183.     

Palliatieve zorg bij dementie en de ontmanteling van de behandelfunctie van het verpleeghuis

Palliative care in dementia and the dismantlement of nursing home medicinePalliative care is mostly restricted to the terminal phase of incurable illness. According to the WHO revised definition palliative care is specifically directed towards patients and families facing life-threatening illness. This definition is not adequate to orient and direct palliative care policies in non-cancer diseases such as dementia. Although dementia is incurable from the outset, its course is often protracted, resulting in a terminal stage only after several years. This disease trajectory necessitates an alternative palliative approach, implying a proactive attitude of nursing home physicians in facilitating early and timely discussions with patients and their proxies on advance care planning and treatment of complications and concomitant diseases. This, together with their specific training in the treatment of the long term sequelae of chronic diseases, defines the success of Dutch nursing home medicine in foregoing inappropriate hospital admissions and providing adequate medical care in the nursing home. However, recent reorganisations of nursing home care and its funding threaten to downgrade the quality of medical care for patients with dementia in Dutch nursing homes by focusing unilaterally on welfare ideology and ‘marketization’ of long term care, thus underestimating the importance of a palliative care policy in dementia.     

Factoren die van invloed zijn op het verwijzen van patiënten van het verpleeghuis naar het ziekenhuis

Introduction

Hospitalisation may cause negative effects on elderly patients. Therefore, it is important that referral and admission of older nursing home patients is well-considered. The aim of this study is to investigate the factors that affect the decision making process.

Method

Questionnaire survey among elderly care physicians and physicians following the elderly care physician training program.

Results

Of the 1,540 surveys, 200 were returned (response rate of 13%). Over 60% of the respondents had referred a nursing home patient to the hospital in the previous month. A stay at a geriatric rehabilitation ward, suspicion of a fracture, a good quality of life, a patient’s or family’s wish for referral, no treatment restrictions, and follow-up appointments in the hospital were factors which made referral to the hospital more likely according to the respondents. Medical specialist consultation and the in hospital presence of a physician specialised in geriatric care were considered to be important. Referral was less likely if a patient was diagnosed with dementia, had a low quality of life or had treatment restrictions.

Conclusion

Both patient-related and non-patient-related factors influence hospital referral of nursing home patients. Further research is needed to determine whether these different factors contribute to the different outcomes of a hospital admission, to facilitate proper decision-making for elderly care physicians.

     

Het verklaren van verschillen in ervaren kwaliteit van leven van kwetsbare ouderen: een ‘mixed-method’ onderzoek

Most research on (multidimensional) frailty focuses on deficits and risks of adverse outcomes. However, frail older people can still report positive outcomes, such as a relatively high QoL. In order to develop more positively oriented prevention strategies, this exploratory study aimed (a) to identify characteristics related to QoL among frail older people; and (b) to explain discrepancies between higher and lower levels of QoL, with a specific focus on strengths frail older people with a higher QoL still may have. Quantitative and qualitative data was gathered by means of semi-structured interviews with Flemish community-dwelling, frail older people with higher (n?=?16) and lower QoL levels (n?=?18). Quantitative analyses showed that frail older people with a higher QoL were older, had lower levels of psychological frailty, and reported higher meaning in life compared to those with a lower QoL. Outcomes of qualitative analysis showed that participants in the high QoL subgroup adapted more effectively to difficulties, had more things in prospect, performed more activities, and were more satisfied with their social network compared to the low QoL subgroup. To conclude, this exploratory study suggests possibilities to promote and improve QoL by strengthening specific resources among frail older people.Please note that an English version of this article has been published in BMC Geriatrics: van der Vorst A, Zijlstra GAR, De Witte N, Vogel RGM, Schols JMGA, Kempen GIJM, D?SCOPE Consortium. Explaining discrepancies in self-reported quality of life in frail older people: a mixed-methods study. BMC Geriatr. 2017;17(1): 251.  https://doi.org/10.1186/s12877-017-0641-y.     

Effecten van geriatrische COPD-revalidatie op ziekenhuisopnames en inspanningstolerantie: een retrospectief observationele studie

Introduction

Frail COPD patients are frequently not accepted for regular pulmonary rehabilitation programs due to low physical condition and functional limitations. Rehabilitation programs in nursing homes for geriatric patients with COPD have been developed. The effects of such programs are largely unknown.

Aims

To assess the course of COPD-related hospital admissions and exercise tolerance in a cohort of frail COPD patients participating in geriatric COPD rehabilitation.

Methods

Retrospective observational study with a follow up of 12 months after discharge from rehabilitation. COPD related hospital admission days were measured in the year before and after participating rehabilitation. Exercise tolerance was measured by the six minute walk test (6MWT) at admission and at discharge from rehabilitation.

Results

Fifty-eight participants accomplished the rehabilitation program. Twelve patients died in the first year after discharge. The median number of hospital admission days in the year before participating rehabilitation was 21 (IQR 10–33). The first year after discharge this was decreased to a median of 6 (IQR 0–12). The 6MWT increased from 194 (SD 85) meters at admission to 274 (SD 95) meters at discharge (mean difference 80 m, SD 72; p < 0.05).

Conclusions

Geriatric COPD rehabilitation in a nursing home setting seems to reduce hospital admissions in frail COPD patients and to increase exercise tolerance.

     

Validatieonderzoek Welzijnsmeter-dementie

The Well-Being Measure – dementia is a digital observation instrument that assesses the well-being of persons with dementia on four domains of quality of life: Mental well-being, Physical well-being, Participation, and Living arrangements. Its goal is to assess the well-being of persons with dementia in an easy and positive way. Besides illness-related symptoms and problems, the instrument also assesses positive aspects of functioning. It visualizes the results and provides specific behavioural advice to the caregivers. The goal of the present article is to conduct a first psychometric analysis: factor structure, reliability (Cronbach’s alpha), concurrent, and convergent validity.Observations were carried out among 168 persons with dementia in eleven different small-scale psychogeriatric wards. Five existing instruments were used among 63 persons to validate the Well-Being Measure-dementia: quality of life, neuropsychiatric symptoms, care dependency, depression, and agitation.The expected factor structure was found in each of the four domains. Coefficients were high on the expected factor and low on the other factor(s). The scale means were on the positive side, but showed an adequate range and variability. Reliability was satisfactory to good. The relation with existing scales was moderate to strong. The pattern of relations was consistent with the measurement intentions of the different existing instruments.The Well-Being Measure – dementia appears to be a valid and reliable scale. Further studies should assess its test-retest reliability, sensitivity to change and relation with the course of dementia. Current experience shows that the instrument is also useful in everyday practice.     

Morbus Parkinson

Monogenic Parkinson’s disease (PD), i.?e. parkinsonism caused by mutations in single genes, represents ~5% of all PD cases. Over the past 20 years, three autosomal dominantly (SNCA, LRRK2, VPS35) and three autosomal recessively (Parkin, PINK1, DJ-1) inherited causal PD genes have been identified and validated. Although pathogenic changes in SNCA are very rare, begin early, and may be associated with the development of dementia, pathogenic variants in LRRK2-linked PD are most common among monogenic PS and patients are clinically indistinguishable from those with idiopathic PD. In patients with onset before the age of 40 years, pathogenic variants in the Parkin and PINK1 genes should be suspected, and in patients with a positive family history, genetic counseling should be carried out. Recently, dynamic developments in the area of Parkinson’s genetics have led to new therapeutic approaches and the first gene-specific therapies have entered the early testing phase. Besides the established monogenic PD genes, candidate genes have been identified, but not yet conclusively validated. In addition to established monogenic PD, as yet unvalidated Parkinson’s candidate genes and well-characterized genetic risk exist at this time. As monogenic PD represents a “model disease” for idiopathic PD too, further progress toward more personalized medicine may be expected for both monogenic and idiopathic PD.     

Toepassing van stemmingsvragenlijsten bij ouderen met alzheimerdementie (met of zonder taalstoornis) en hun informanten

Introduction

Alzheimer’s Dementia (AD) may be associated with symptoms of depression. In AD, problems of language expression or understanding will arise sooner or later. The aim of this study was to determine whether elderly persons with AD, with or without a language disorder, experience difficulties understanding and answering mood related questions. In addition to this, it was our object to test the validity of the answers of nurses as informants, on the mood of an elderly client.

Methods

53 elderly persons, living in care homes, and their nurses, took part in the study. 25 participants had been diagnosed with Alzheimer’s disease, 28 participants had no cognitive impairment. Language skills were tested using the SAN-test (Stichting Afasie Nederland) and subtests of the Aachen Aphasia Test (AAT). Mood was assessed with the Beck Depression Inventory-second edition (BDI-II-NL) and the Geriatric Depression Scale (GDS-30).

Results

There were no significant differences in scores on the mood related questionnaires between participants without cognitive impairment and participants with Alzheimer’s disease, with or without a language disorder. The correlation between self- and informant-rating was very limited. In general, nurses reported more depressive symptoms than the elderly persons did themselves. Disparities between self- and informant-ratings varied from informant scores overestimating low self-ratings of depression to informant scores underestimating high self-ratings.

Conclusion

Alzheimer’s disease, whether or not it is complicated by a language disorder, does not disturb the normal score distribution on either test (BDI or GDS). This means that elderly persons with Alzheimer’s disease are capable of adequately answering questions related to their own mood. However, considerable discrepancies were found between observer- and self-ratings of emotional wellbeing. Therefore it is important to not only take into account the information of an informant when testing for depression, but also the elderly person’s own assessment of their mood.

     

Impact of neutrophil-to-lymphocyte ratio on periprocedural myocardial infarction in patients undergoing non-urgent percutaneous coronary revascularisation

Background

Pro-thrombotic conditions importantly influence myocardial perfusion and procedural results after percutaneous coronary intervention (PCI). The neutrophil-to-lymphocyte ratio (NLR) has emerged as a predictor of cardiovascular events and of long-term prognosis, especially in ST-elevation myocardial infarction patients undergoing primary PCI. The aim of our study was to evaluate the role of NLR on periprocedural myocardial infarction (MI) in patients undergoing non-urgent PCI.

Methods

In a consecutive cohort of 1542 patients undergoing PCI, myonecrosis biomarkers were determined at 6, 12, 24 and 48 hours post-procedure. Patients were divided into quintiles according to NLR values. Periprocedural myonecrosis was defined as a troponin I increase of 3 times the upper limit of normal or as 50?% of an elevated baseline value, whereas periprocedural MI was defined as a CK-MB increase of 3 times the upper limit of normal or 50?% of baseline.

Results

Higher NLR was related to age, established risk factors and cardiovascular history. NLR was associated with severe coronary artery disease (p = 0.009), tighter stenosis (p < 0.001), coronary calcifications (p = 0.005), intracoronary thrombus or thrombectomy use (p < 0.001), TIMI flow pre- and post-PCI (p < 0.001), and inversely to restenosis (p = 0.04) and use of a drug-eluting stent (p = 0.001). NLR did not influence the occurrence of myonecrosis (p = 0.75; adjusted OR (95?% CI) = 0.99 (0.63–1.54), p = 0.96), but was associated with a higher occurrence of periprocedural MI, even after correction for baseline differences (p = 0.03; adjusted OR (95?% CI) = 1.33 (1.02–2.3), p = 0.02), with NLR ≥ 3 best predicting the risk of periprocedural MI at the receiver operating characteristic curve analysis.

Conclusion

In patients undergoing non-urgent PCI, a higher NLR increases the risk of periprocedural MI, especially for values ≥ 3.

     

Ontwikkeling van algoritmes voor oordeelkundig gebruik van psychofarmaca bij ouderen met verhoogd valrisico

Psychotropic drugs (hypno-sedatives, antidepressants and antipsychotics) are commonly used in the older population. On the long term, psychotropic drug use in older persons is associated with several negative functional outcomes such as an increased risk of falls. Gradual withdrawal of psychotropic drugs in older persons is feasible and leads to a significant reduction of falls. Both withdrawal of psychotropic drugs as well as the initiation of appropriate treatment with psychotropic drugs requires knowledge, consultation and cooperation between disciplines and a mentality change among healthcare professionals. In order to inform and support healthcare professionals, the Centre of Expertise for Fall and Fracture Prevention Flanders developed three clinical practice algorithms for the appropriate use of psychotropic drugs in older persons with high risk of falls and a fact sheet with background information.     

Implementatie van een proactief zorgprogramma voor kwetsbare ouderen in de huisartsenpraktijk: van onderzoek naar praktijk

Background

Multimorbidity, functional impairment and frailty among community-dwelling older people are causing increasing complexity in primary care. A proactive integrated primary care approach is therefore essential. Between October 2014–2015, an evidence-based proactive care program for frail older people was implemented in the region Noord-West Veluwe en Zeewolde, the Netherlands. This study evaluated the feasibility of the implementation, having a strong focus on the collaboration between the medical and social domain.

Methods

Using a mixed-methods design we evaluated several process indicators. Data were obtained from electronic routine medical record data within primary care, questionnaires, and interviews with older adults. The questionnaires provided information regarding the expectations and experiences towards the program and were sent to health care professionals at baseline and six months follow-up. Stakeholders from various domains were asked to fill in the questionnaire at baseline and twelve months follow-up. Interviews were conducted to explore the experiences of older adults with the program. Regional work groups were set up in each municipality to enhance the interdisciplinary and domain transcending collaboration.

Results

The proactive primary care program was implemented in 42 general practices who provided care to 7904 older adults aged 75 years or older. A total of 101 health care professionals and 44 stakeholders filled in the questionnaires. The need for better structure and interdisciplinary cooperation seemed widespread among the participants. The implementation resulted in a positive significant change in the demand for a better regional healthcare-framework (34% p ≤ .001) among health care professionals, and the needs for transparency regarding the possibilities for referral improved (27% , p = .009). Half of the participants reported that the regional collaboration has been improved after the implementation. Health care professionals and stakeholders gained increased attention and awareness of frail elderly in their area compared to before the implementation. Older people and their caregivers were positive about the proactive approach. The nurses reported that the screenings questionnaire was too lengthy and therefore time consuming.

Conclusions

The implementation of the proactive primary care approach in daily practice was feasible. A strong interdisciplinary collaboration was realized. The program was easily adapted to the local context.