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.     

Een cultuurvergelijkend onderzoek naar behandelbesluiten van artsen met betrekking tot demente verpleeghuispatiënten met pneumonie

A cross-cultural study of physician treatment decisions for demented nursing home patients who develop pneumoniaThis qualitative interview study in the Netherlands and North Carolina (US) found that physician treatment decisions are influenced by contextual differences in physician training and healthcare delivery in the US and the Netherlands. Dutch physicians treating nursing home residents with dementia and pneumonia assumed active, primary responsibility for treatment decisions while US physicians were more passive and deferential to family preferences, even in cases where they considered the families’ wishes inappropriate. Dutch physicians knew their patients well and made treatment decisions based on what they perceived was in the best interest of the patient while US physicians reported limited knowledge of their nursing home patients due to a lack of contact time. Efforts to improve care for patients with poor quality of life who lack decision-making capacity must consider the context of societal values, physician training, and the processes by which physicians negotiate patient and family preferences.     

A cross-cultural study of physician treatment decisions in relation to demented nursing home patients who develop pneumonia

This qualitative interview study in The Netherlands and North Carolina (US) found that physician treatment decisions are influenced by contextual differences in physician training and healthcare delivery in the US and The Netherlands. Dutch physicians treating nursing home residents with dementia and pneumonia assumed active, primary responsibility for treatment decisions while US physicians were more passive and deferential to family preferences, even in cases where they considered the families' wishes inappropriate. Dutch physicians knew their patients well and made treatment decisions based on what they perceived was in the best interest of the patient while US physicians reported limited knowledge of their nursing home patients due to a lack of contact time. Efforts to improve care for patients with poor quality of life who lack decision-making capacity must consider the context of societal values, physician training, and the processes by which physicians negotiate patient and family preferences.     

Premorbid personality and aggressive behavior in residents of psychogeriatic nursing homes

In the present study, the correlation was examined between pre-morbid personality traits and the occurrence of aggressive behaviour in residents of a psychogeriatric nursing home. The participants in the study were the close relatives of 39 residents of a psychogeriatric nursing home. These residents were selected on the basis of two subscales of the BOP assessment scale for elderly patients: Aggressive and annoying behaviour, and mental disability. Residents were divided into two groups: one group did not display aggressive behaviour, the other group displayed a great deal of such behaviour. The groups were comparable with regard to the degree of mental disability. To ascertain pre-morbid personality traits, use was made of the hetero-anamnestic personality questionnaire (HAP) and the Quick Big Five (QBF). We found no significant differences in any of the premorbid personality traits between the two groups. We could not confirm the conclusion of other authors that emotional lability (neuroticism) is a personality trait which makes people susceptible to developing aggressive behaviour. In conclusion, our study did not confirm the hypothesis that pre-morbid personality traits are useful to explain the occurrence of aggressive behaviour in residents of a psychogeriatric nursing home.     

Cognitive and behavioural impairment among elderly people in institutions providing different levels of care.

OBJECTIVE: To compare the prevalence and degree of cognitive and behavioural impairment in elderly patients in institutions providing different levels of care. DESIGN: Prevalence study. SETTING: A nursing home, a home for the aged and psychogeriatric wards in a provincial psychiatric hospital. PATIENTS: Only subjects 65 years of age or older were eligible for inclusion. A random sample was selected comprising 25% of the residents in the nursing home and the home for the aged; of the 119 asked to participate 95 agreed (44 in the nursing home and 51 in the home for the aged). All 50 on the psychogeriatric wards agreed to participate. MAIN OUTCOME MEASURES: The Mini-Mental State Examination (MMSE) and the Kingston Dementia Rating Scale (KDRS). RESULTS: An MMSE score of less than 24 (cognitive impairment) was given to 37 (84%) of the residents in the nursing home, 43 (84%) of those in the home for the aged and 48 (96%) of the patients in the psychiatric hospital; the corresponding numbers for a KDRS score of more than 0 (cognitive impairment) were 41 (93%), 48 (94%) and 50 (100%). The seven patients receiving the highest level of care at the home for the aged (special care) had more behavioural problems than those in the psychiatric hospital did (p less than 0.001). CONCLUSIONS: Cognitive and behavioural impairment was widespread in the three institutions regardless of the level of care. When planning services and allocating resources government funding agencies should consider the degree and prevalence of such impairment among elderly people in institutions.     

De nieuwe redactieadviesraad van het Tijdschrift voor Gerontologie en Geriatrie

It is unknown how often choking occurs in geriatric wards and in nursing homes and what the treatment and outcomes are in regular practice. A questionnaire was sent to Dutch geriatricians (N = 130), nursing home physicians (N = 130), and trainees for these disciplines (N = 215), in order to gain information about the experience, practice and competence of physicians in choking in geriatric and nursing home patients. We also analysed to what extent geriatric and nursing home wards were prepared for accurate handling of choking. The response rate was 30%. More than half of the responders had experienced an episode of food choking at least once in the past five years. The mortality rate in the reported cases was high (30%). The majority of the patients who died of choking had not received the Heimlich-manoeuvre. Physicians who had attended resuscitation training long ago felt as competent to manage a choking episode as physicians that had recently attended resuscitation training. Of all geriatric wards and nursing homes, the majority lacked a guideline on how to handle in acute food choking. Geriatric wards and nursing homes do not seem to be well prepared for acute food choking in several aspects. Despite methodological shortcomings of this study, the results underline the necessity of clarification of the terms used, and development and implementation of guidelines for this important problem.     

National Survey of Endocrinologists and Surgeons Regarding Active Surveillance for Low-Risk Papillary Thyroid Cancer

ObjectiveActive surveillance for low-risk papillary thyroid cancer (PTC) was endorsed by the American Thyroid Association guidelines in 2015. The attitudes and beliefs of physicians treating thyroid cancer regarding the active surveillance approach are not known.MethodsA national survey of endocrinologists and surgeons treating thyroid cancer was conducted from August to September 2017 via professional society emails. This mixed-methods analysis reported attitudes toward potential factors impacting decision-making regarding active surveillance, beliefs about barriers and facilitators of its use, and reasons why physicians would pick a given management strategy for themselves if they were diagnosed with a low-risk PTC. Survey items about attitudes and beliefs were derived from the Cabana model of barriers to guideline adherence and theoretical domains framework of behavior change.ResultsAmong 345 respondents, 324 (94%) agreed that active surveillance was appropriate for at least some patients, 81% agreed that active surveillance was at least somewhat underused, and 76% said that they would choose surgery for themselves if diagnosed with a PTC of ≤1 cm. Majority of the respondents believed that the guidelines supporting active surveillance were too vague and that the current supporting evidence was too weak. Malpractice and financial concerns were identified as additional barriers to offering active surveillance. The respondents endorsed improved information resources and evidence as possible facilitators to offering active surveillance.ConclusionAlthough there is general support among physicians who treat low-risk PTC for the active surveillance approach, there is reluctance to offer it because of the lack of robust evidence, guidelines, and protocols.     

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.     

"Natural cause of death or not?" How do nursing home physicians act when in doubt of natural cause of death?

The objective of the study was to explore if nursing home physicians act by law, when they doubt the natural cause of death. In May 1999, a questionnaire was sent to 153 nursing home physicians in the region of Utrecht and Nijmegen. They were asked if they consult the coroner when they have doubts about the natural cause of death. Eighty-six percent (104) returned the questionnaire. Thirty-two percent of the nursing home physicians always consult the coroner and 52% does so most of the time. Only 12% does not consult the coroner most of the time and 2% never does. The main reasons for not consulting the coroner were that nursing home physicians judge a death after a fall as an incident that fits in the descending lifeline of patients and that some nursing home physicians had bad experiences consulting the coroner. We conclude that this policy may lead to underregistration of unnatural deaths. Changing the definition or changing the law may reduce this problem. Education and information can also contribute to change in physician's attitudes.     

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.

     

Experience of family members with the decision concerning artificial nutrition and hydration in people with dementia in nursing homes

The purpose of this study is to investigate how relatives of nursing home patients with dementia, for whom the decision whether to start or forgo artificial nutrition and hydration (ANH) was made, assess the decision-making process. Furthermore we evaluated the information given by the nursing home staff to the relatives and the care provided by them to the patient. The study was an observational study based on written questionnaires. Relatives of 99 nursing home patients with dementia filled in a questionnaire at the time of the decision-making and 6 weeks after the decision was made or 6 weeks after the patient had died. Almost all relatives assessed the 4 aspects of the decision-making process (number of consults, content of the consults, carefulness of the decision-making and there own part in the decision-making process) at both times as 'good' or 'satisfactory'. Furthermore it appeared that they judged the carefulness of the decision-making process significantly more often as 'good' when they also assessed the other three aspects as 'good'. Especially their own influence on the decision-making process appeared to play a part in this matter. Information about the possible consequences of starting ANH as well as about the condition of the patient were experienced sufficient by almost all relatives. This was also the case for the care offered to the patient. In general almost all relatives reported satisfaction with the decision and with the carefulness of the decision-making process. This satisfaction did not differ between the moment of the decision and afterwards. For this it did not make any difference whether the patient had or had not died.     

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.     

Geriatrisch spreekuur door een specialist ouderengeneeskunde in de huisartspraktijk

An innovative project is presented, in which general practitioners, an elderly care physician and specialized nurses work together. The primary aim of the project was early detecting of frail community dwelling elderly and to give them adequate treatment and support, to enable them to stay in their own home situation as long as possible. The detection of frail elderly was performed by mean of the Easycare instrument. Results collected from October 2007 - July 2009 are presented in this article. The findings show that particularly elderly with symptoms of dementia have been detected. The main actions were provision of integrated psychogeriatric care according to a tailormade integral care plan and starting or extending home care. Elderly with somatic problems were seen mostly in one time consultations. The satisfaction about the care provided in the project was high, both for participating patients and professionals. In the pilot a tendency was also found towards fewer referrals to hospital (specialists) and towards a reduction of the number of acute admissions to the nursing home.     

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     

Psychogeriatric Ward for Mentally Disturbed Elderly Patients

The operation is described of a special psychogeriatric ward of 23 beds set up in 1967 to provide treatment for mentally disturbed elderly patients who could not be kept in a general ward or at home. The unit is in a predominantly geriatric hospital which serves a population of 340,000 and in the four and a half years reviewed 600 patients were admitted. Half of the admissions were emergencies. A consultant geriatrician was in charge and the nursing staff were general trained. The number of beds was found to be adequate for the demand. Few patients had to be transferred to a psychiatric hospital, but, since the mental disturbance was often associated with severe illness and the patients were old, the death rate was high. The nursing staff have found the work interesting and stimulating.     

A psychogeriatric survey of old people's homes.

An assessment of mental impairment and behavioral disabilities in 289 residents in six old people''s homes indicated that 50.6% were probably demented and 54% needed considerable help in daily living, 74% were taking prescribed medication, and 11% were taking four or more prescribed drugs. There was a wide variation between homes in those rated as behaviourally disabled, and in the amount of medication prescribed. A follow-up of 60 mentally impaired residents showed few remediable psychiatric disorders or psychotoxic drug effects. A community psychiatric nurse working with the psychogeriatric team would provide a useful support service to old people''s homes, particularly where there is a high proportion of disturbed residents and where the staff lack nursing experience.     

Infecciones respiratorias

Respiratory tract infection is a leading cause of mortality and hospitalization in nursing home residents. As a result, interest has increased in the epidemiology of these infections. However, several issues remain to be systematically evaluated due to the lack of clinical trials. Few studies have compared different antibiotic treatment strategies and outcomes.Nursing home residents with pneumonia are frequently hospitalized and these transfers are associated with the multiple hazards of hospitalization as well as with economic costs. Several predictive models have been developed to help clinicians identify residents at low and high risk of mortality. This present article analyzes the relevant literature and attempts to provide information of help in dayto-day decision-making in nursing homes.