Preventie en behandeling van osteoporose bij kortdurende revalidatie in het verpleeghuis: een taak voor de verpleeghuisarts

Prevention and treatment of osteoporosis in short stay departments of nursing homes: a nursing home physician’s task. This research shows that nursing home physicians might play an important part in the diagnostics and treatment of vitamin-D deficiency. 96 rehabilitating elderly who had undergone a hip operation were investigated. 36% had a vitamin-D deficiency (vitamin-D<30nmol/l). Vitamin-D deficiency was 53 % in the fracture group and 26 % in the arthritis group. Deficiencies were treated with vitamin-D medication. After the patient’s discharge the general practitioner was sent a questionnaire. The results show that general practitioners agree to nursing home physicians’ investigating vitamin-D deficiencies and to nursing home physicians’ initiating vitamin-D medication in case of a deficiency. The general practitioners themselves do not often investigate vitamin-D deficiency. Tijdschr Gerontol Geriatr 2007; 38:147-153     

Problems of care in a private nursing home.

To assess problems of care in a private nursing home an observational study was carried out over two months, during which a research nurse worked as a member of the staff in a home caring for 25 patients aged 62-90. During the second month a consultant physician visited the home weekly to hold case conferences and assess each patient''s functional ability and drug regimen. Various problems in medical, nursing, and bureaucratic matters were identified--for example, staff failed to understand the appropriate response to various medical symptoms; no clear policy existed for managing pressure sores; and one patient''s anticoagulant state could not be assessed when industrial action meant that transport to take him to hospital was not available--and several changes in drug treatments were recommended. The problems that were identified were mainly due to poor communication between the home and general practitioners and hospitals and to the lack of guidance policy on common issues that arise in long term care. Such a policy could be produced by health authority staff, general practitioners, and representatives of nursing homes.     

Old people not known to the general practitioner: low risk group.

The elderly patients in a large general practice aged 75 and over who lived at home (n = 877) were divided into two groups according to the general practitioner''s knowledge of their risk status and were designated "risk status known" (n = 679) and "risk status not known" (n = 198). Forty-three high risk patients in the risk status known group had a functional disability score and experience of mortality that was not dissimilar to those of elderly people in institutions. The medical and social characteristics of a random sample (n = 150) of the risk status known group, after excluding the high risk patients, were compared with the risk status not known group using a Barber Wallis questionnaire. A response rate of 90% was achieved from both groups and a cumulative risk score was calculated by totalling unfavourable replies to the questions. The risk status not known group, which comprised 14% of the patients who lived at home after correcting for the number who had died and moved, had appreciably less contact with the general practitioners, had an appreciably lower cumulative risk score, were confined at home less because of ill health, were less concerned about their health, and were less in need of nursing attention. The findings of this study suggest that the elderly patients who are not known to their general practitioners are in relatively good health when compared with the patients that the general practitioner knows well.     

General Practitioner's View of the Home Nursing Service

A postal questionary concerned with possible developments in the home nursing service was sent to a random sample of 500 principals in general practice in Scotland in late February 1967 and was completed by 444 (89%). Only 13% of the respondents had a district nursing sister attached to their practice organization, but 70% of the remainder wanted this. The most frequently expected benefit was that she could undertake procedures at present performed by the doctor. Half the respondents thought that at present the district nursing sister did not use her professional training and skills fully. Most general practitioners agreed that a State-enrolled nurse, working under supervision, could do some of the jobs now performed by the district nursing sister.     

Prevalence of xerostomia and hyposalivation in the nursing home and the relation with number of prescribed medication

In nursing homes, the number of patients with their own dentition increases. Many of them, however, are unable to perform oral hygiene procedures. Medication is considered to be an important cause of hyposalivation, which may lead to oral alterations and loss of teeth. The aim of the present study was to investigate the prevalence of xerostomia and hyposalivation in a Dutch nursing home and to examine the possible relation with medication usage. Between January and March 2001, the salivary flow rates were measured in 50 patients residing in a nursing home in Amsterdam. Unstimulated saliva, parafilm-stimulated saliva and citric acid stimulated saliva were determined. Xerostomia was determined by the question "My mouth feels dry" and the medication used was examined. The data were analysed with (M)ANOVA. The average age of the patients was 78.1 +/- 9.7 years. Forty-eight % of the patients had an unstimulated flow rate of less then 0.20 ml/min and 24% had a flow rate even lower than 0.10 ml/min (reference values: 0.25-0.50 ml/min). The flow rate of women was significantly lower than that of men (p < 0.01), even after correction for age, smoking and the number of prescribed medications. Salivary flow rates decreased significantly with age (p < 0.05). The number of prescribed medication was significantly higher in patients over the age of 70 (p < 0.01, n = 42) and also in women (p < 0.01). The prevalence of xerostomia was 52% with no difference between men and women. In nursing homes, the prevalence of hyposalivation and xerostomia is high. The number of xerogenic medications used seems to be an important factor. Women and patients aged over the age of 70 years need special attention with respect to oral health.     

Patients with Korsakoff's syndrome in a nursing home: characteristics and comorbidity

This article presents characteristics and co-morbidity of patients with Korsakoff's syndrome after admission to a nursing home. The medical charts were studied of all patients with Korsakoff's syndrome, admitted between 1984 and 1998 to the special ward for Korsakoff patients of a nursing home in the eastern part of the Netherlands. The 'Standard of classification for diseases in nursing homes' ('Standaard van classificatie voor ziekten in de verpleeghuisgeneeskunde') was used to classify co-morbidity. The group included 77 patients. Almost 75% were male. The average age was 53 years on admission. More than 50% of the patients were divorced. After admission, 30% of the group was transferred to a different setting. The estimated average follow-up period was 7.1 year. Patients had 2.9 co-morbid conditions at admission. Diseases due to alcoholism were frequently diagnosed. During the stay skin diseases, psychological disorders and behavioural disorders were frequently noticed. The prevalence of cognitive impairment and alcohol dementia was surprisingly high. Thirteen patients died, most of them of cancer or combined cardiovascular and respiratory diseases. We conclude that patients with Korsakoff's syndrome are an unexplored area in nursing homes. This group of nursing home inhabitants shows its own characteristics and co-morbidity.     

Evalution of Home Nurse Attachment in Bristol

By the end of June 1969 home nurses in Bristol were attached to 18 general practices caring for about 137,000 patients, or about one-third of the city''s population. Attachment was associated with an increase by about one-third in the number of patients referred by general practitioners for home nursing. Additional benefits derived from attachment during the nine months from January to September 1969 were 2,047 items of service performed by nurses in general practitioners'' surgeries, 65 home visits to patients who were not receiving domiciliary nursing care, improved communications between general practitioners and nurses, and opportunities for both doctors and nurses to widen their fields of work. The travelling expenses paid to Bristol''s nurses increased by 9·5%.It is suggested that the benefits to patients, doctors, and nurses of attachment far outweigh the costs and that there is scope for extending the role of the attached nurse in the surgery and in home visiting.     

Paediatric home nursing scheme in Gateshead.

A scheme to provide specialised nursing care for sick children in their own homes was begun in Gateshead in 1974. Selected district nurses were retrained in the paediatric unit on which the scheme was based and nursed at home 22 children referred to them by general practitioners as the alternative to hospital admission and 39 discharged to their care by the hospital. Most of the children were aged 3 years or less and came from working-class homes. Most of the mothers who were asked were in favour of the scheme.     

Factors affecting early unplanned readmission of elderly patients to hospital.

A random sample of 133 elderly patients who had an unplanned readmission to a district general hospital within 28 days of discharge from hospital was studied and compared with a matched control sample of patients who were not readmitted. The total group was drawn from all specialties in the hospital, and by interviewing the patients, their carers, the ward sisters, and the patients'' general practitioners the factors causing early unplanned readmission for each patient were identified. Seven possible principal reasons were found: relapse of original condition, development of a new problem, carer problems, complications of the initial illness, need for terminal care, problems with medication, and problems with services. There were also contributory reasons, and it was usual for several of these to be present in each case. The unplanned readmission rate was 6%; the planned readmission rate was 3%. It was thought that unplanned readmission was avoidable for 78 (59%) patients. Patients in the study group and in the control group showed significant differences in certain characteristics--such as low income, previous hospital admission, already having nursing care, and admission by general practitioners--and this might help to identify patients who are likely to be readmitted in an emergency.     

Psychiatric consultation in the nursing home. An inquiry among Amsterdam nursing home physicians

Psychiatric disorders are common among nursing home residents. However, little is known about psychiatric consultation in Dutch nursing homes. As an exploration of the topic, Amsterdam-based nursing home physicians were asked to rate a number of aspects of psychiatric consultation as performed in their nursing home. Striking differences are reported between 14 participating nursing homes with regard to the intensity of psychiatric consultation and the number of consultation requests, which seems low compared with the perceived psychiatric problems. Somatically ill and psychogeriatric residents are estimated to generate an equal number of consultation requests. Psychiatric consultation appears to be characterized by diagnostic clarification, medication recommendations and behavioral management advice whereas staff-directed activities are scarce. Physicians report shortcomings in psychiatric skills among care staff. Research is necessary concerning the psychiatric care delivered to nursing home residents, as well as with regard to the optimal model for psychiatric consultation services. Integration of psychiatric care in nursing homes with mental health care services appears to be desirable.     

Nationwide study of decisions concerning the end of life in general practice in The Netherlands.

OBJECTIVE--To gain insight into decisions made in general practice about the end of life. DESIGN--Study I: interviews with 405 physicians. Study II: analysis of death certificates with data obtained on 5197 cases in which decisions about the end of life may have been made. Study III: prospective study with doctors from study I: questionnaires used to collect information about 2257 deaths. The information was representative for all deaths in the Netherlands. RESULTS--Over two fifths of all patients in the Netherlands die at home. General practitioners took fewer decisions about the end of life than hospital doctors and doctors in nursing homes (34%, 40%, and 56% of all dying patients, respectively). Specifically, decisions to withhold or withdraw treatment to prolong life were taken less often. Euthanasia or assisted suicide, however, was performed in 3.2% of all deaths in general practice compared with 1.4% in hospital practice. In over half of the cases concerning pain relief or non-treatment general practitioners did not discuss the decision with the patient, mostly because of incapacity of the patient, but in 20% of cases for "paternalistic" reasons. Older general practitioners discussed such decisions less often with their patients. Colleagues were consulted more often if the general practitioner worked in group practice. CONCLUSION--Differences in work situation between general practitioners and hospital doctors and differences between the group of general practitioners contribute to differences in the number and type of decisions about the end of life as well as in the decision making process.     

An investigation into general practitioners associated with high patient mortality flagged up through the Shipman inquiry: retrospective analysis of routine data

Objective To identify a credible explanation for the excessively high mortality associated with general practitioners who were flagged up by the Shipman inquiry.Design Retrospective analysis of routine data.Setting Primary care.Participants Two general practitioners in the West Midlands who were associated with an unacceptably high mortality of patients during 1993-2000.Main outcome measures Observed and expected number of deaths and deaths in nursing homes.Results Preliminary discussions with the general practitioners highlighted deaths in nursing homes as a possible explanatory factor. No relation was found between the expected number of deaths and deaths in nursing homes in each year during 1993-2000 for either general practitioner. In contrast, the magnitude and shape of the curves of a cumulative sum plot for excess number of deaths (observed minus expected) in each year were closely mirrored by the magnitude and shape of the curves of the number of patients dying in nursing homes; and this was reflected in the high correlations (R² = 0.87 and 0.89) between excess mortality and the number of deaths in nursing homes in each year for the general practitioners. These findings were supported by administrative data.Conclusions The excessively high mortality associated with two general practitioners was credibly explained by a nursing home effect. General practitioners associated with high patient mortality, albeit after sophisticated statistical analysis, should not be labelled as having poor performance but instead should be considered as a signal meriting scientific investigation.     

Midlife obesity and long-term risk of nursing home admission

Objective: Obesity is a growing problem among middle‐aged individuals. We investigated whether obesity in middle‐aged individuals influences the need for future nursing home care and whether the risk of nursing home admission associated with obesity is greater in whites than in blacks. Research Methods and Procedures: The study population (N = 8804) consisted of long‐term members of the Kaiser Permanente Medical Care Plan ages 75 to 85 years in 1995 who had completed a standardized, multiphasic health checkup while in their 50s. The multiphasic health checkup examinations were performed as part of routine medical care between the years 1964 and 1973 and included standardized measurements of BMI. We used health plan records to assess incident nursing home admissions from 1995 to 2002. The risk of nursing home admission associated with standard categories of midlife BMI was estimated using Cox proportional hazard analysis. Results: During an average follow‐up of 5.1 years, the nursing home admission rate was 6.8 per 100 person‐years of observation. After adjustment for comorbidities, midlife obesity predicted incident nursing home admission ～25 years later [hazard ratio (HR), 1.30; 95% confidence interval (CI), 1.15 to 1.46; p < 0.001]. Overweight BMI at midlife was not associated with future nursing home admission (HR, 1.05; 95% CI, 0.97 to 1.14; p = 0.23). The risk of nursing home admission associated with midlife obesity was higher in whites (HR, 1.34; 95% CI, 1.17 to 1.54; p < 0.001) than in blacks (HR 1.15; 95% CI, 0.87 to 1.52; p = 0.32), but the difference between races was not significant (p for interaction = 0.65). Discussion: Obesity among middle‐aged individuals is associated with an increased risk of nursing home admission in late life and may be an important target for reducing the future societal burden of nursing home care.     

Evaluation of Health Centre Community Nurse Team

This report gives an account of the work during six months of a community nurse team attached to the doctors working from a new health centre. The team consisted of two community nurses, who had both health visiting and Queen''s nursing qualifications, and a State-enrolled nurse. The community nurses, in addition to undertaking all the health visiting for the population at risk, assessed the social and nursing needs of patients at the request of the general practitioners and ensured that these needs were met. When necessary they undertook practical nursing tasks in the home and in the health centre, but most of the bedside nursing in the home was done by the State-enrolled nurse.The needs of the population at risk were such that only one State-enrolled nurse could usefully be employed, and this proved to be a considerable disadvantage. Despite this, the experimental work pattern held advantages to patients, doctors, and nurses, and is potentially capable of providing a satisfying and economic division of responsibilities, with different tasks being carried out by the individual most appropriately qualified.     

Diagnosis of urogenital Chlamydia trachomatis infection in women based on mailed samples obtained at home: multipractice comparative study.

OBJECTIVE: To compare urine and vaginal flush samples collected by women at home with endocervical and urethral swabs obtained by general practitioners for their efficacy in the diagnosis of urogenital Chlamydia trachomatis infection. DESIGN: Multipractice comparative study. SETTING: 33 general practices and a central department of clinical microbiology in Aarhus County, Denmark. SUBJECTS: 222 women aged 18-25 years who for any reason had a gynaecological examination. INTERVENTIONS: Endocervical and urethral swabs were obtained by the women''s general practitioners. The same women when at home then collected a first void urine sample, a midstream urine sample, and a vaginal flush sample (using a vaginal pipette) and mailed them to the laboratory. MAIN OUTCOME MEASURES: C trachomatis defected by the polymerase chain reaction and the ligase chain reaction. Eight tests for C trachomatis were performed for every woman. When two of the eight yielded positive results the patient was considered infected. RESULTS: The overall prevalence of C trachomatis infection was 11.2% (23/205 women). Test sensitivities in samples obtained by general practitioners, samples obtained at home subjected to polymerase chain reaction, and samples obtained at home subjected to ligase chain reaction were 91%, 96%, and 100% respectively. The corresponding specificities were 100%, 92.9%, and 99.5%. CONCLUSIONS: The diagnostic efficacy of samples obtained by women at home and mailed to the laboratory was as good as for samples obtained by a general practitioner when using the ligase chain reaction. This may have important implications for the practicability of screening for this common, often asymptomatic, and treatable infection.     

Treatment of insomnia in demented nursing home patients: a review

Insomnia and fragmentation are features of the sleep of these patients. In order to list the factors disturbing the sleep of demented nursing home patients and the interventions improving their sleep quality, the literature was reviewed. A Medline search over the period 1966-2000 was performed. This resulted in 22 research articles. Admission to a nursing home is associated with sleep disturbances caused by patient problems (e.g. pain), care routines (e.g. nightly nursing round) and environment (e.g. noise). There are indications that the use of hypnotics in nursing home patients is not always effective and increases the risk of falls. There are several ways to reduce hypnotic consumption in nursing homes. Non-pharmacological interventions to decrease sleep disturbances caused by environmental factors have a favourable although weak effect on sleep itself. By reducing nightly noise, sleep quality does not necessarily improve. Light therapy seems to be the most effective non-pharmacological method to strengthen the circadian sleep/wake rhythm. The struggle against insomnia without using medication perhaps requires a two tracks management: detection and elimination of disturbing environmental factors and implementation of an adequate method to strengthen the circadian sleep/wake rhythm.     

Operations for hernia and varicose veins in a day-bed unit.

Over eight years (1970-8) 1055 patients underwent operations for hernia or "major" varicose veins in a day-bed unit. Here, 608 were discharged home on the day of operation, 262 were transferred to a convalescent hospital for 48 hours, and 161 were retained in the acute ward as part of a controlled trial. Special emphasis was placed on selection and preadmission screening. Failure of planning was uncommon in that only 2.5% were detained in hospital and 1% had to be readmitted. About one-quarter of the patients had complications but these were generally trivial and were satisfactorily treated by the community nursing sisters or general practitioners, or both. Analysis of the total operations for hernia or varicose veins in the unit over the past 19 years shows that, whereas formerly all patients with these conditions were admitted to the main surgical ward, nowadays almost all are managed either by day care or in a five-day ward.     

Myocardial infarction: a comparison between home and hospital care for patients.

To compare the results of home and hospital treatment in men aged under 70 years who had suffered acute myocardial infarction within 48 hours 1895 patients were considered for study in four centres in south-west England. Four-hundred-and-fifty patients were randomly allocated to receive care either at home by their family doctor or in hospital, initially in an intensive care unit. The randomised treatment groups were similar in age, history of cardiovascular disease, and incidence of hypotension when first examined. They were followed up for up to a year after onset. The mortality rate at 28 days was 12% for the random home group and 14% for the random hospital group; the corresponding figures at 330 days were 20% and 27%. On average, older patients and those without initial hypotension fared rather better under home care. The patients who underwent randomisation were similar to those whose place of care was not randomised, except that the non-randomised group contained a higher proportion of initially hypotensive patients, whose prognosis was poor wherever treated. These results confirm and extend our preliminary findings. Home care is a proper form of treatment for many patients with acute myocardial infarction, particularly those over 60 years and those with an uncomplicated attack seen by general practitioners.