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.     

Over het gebruik van d-glutaminezuur bij het bacteriologische wateronderzoek

Samenvatting In het d-glutaminezuur werd een chemisch zuivere, relatief goedkoope stof gevonden, die het pepton in de voedingsbodems voor het bacteriologische wateronderzoek lijkt te kunnen vervangen; waarmede de moeilijkhedem uit de wereld zouden zijn, die, vooral bij het colionderzoek, kleven aan het gebruik van peptonen van verschillende herkomst. Hoewel het niet mogelijk bleek, de false presumptive tests geheel te vermijden, wordt toch het voordeel groot genoeg geacht om een proefneming op grooteren schaal in waterleidingbedrijven aan te bevelen.Summary The fact is stressed, that in bacteriological wateranalysis many false presumptive tests occur, where B. coli can not be isolated from strongly fermenting tubes. The view is held, that an improvement may be possible, when substituting peptone by a nitrogen compound, that is easily taken by B. coli and not by the organisms causing the false presumptive test. Therefore d-glutamic acid (as a sodium- or ammoniumsalt) is tried and found to be perfectly suitable to grow B. coli, but equally good to the other organisms. Nevertheless glutamic acid has a distinct advantage on peptone, being a chemically pure and relatively cheap substance, so that difficulties, arising from the use of different brands of commercial peptones, of unknown composition, may be avoided. Investigation of natural waters, using a solution of 1 % lactose, 1 % glutamic acid, 0.1% K₂HPO₄ and 0.05 % MgSO₄ in distilled water, coloured with bromo thymol blue and neutralised with sodium hydroxide to p₄ 7.0, gives the same results as the same liquid, wherein peptone (Witte) substitutes the glutamic acid. Further experience will have to decide on its suitability in large scale practice.     

Problemen en wensen van mantelzorgers van mensen met dementie: een vergelijking tussen de beginfase en latere fasen in het ziekteproces

This paper investigates whether informal caregivers of persons who have had symptoms of dementia for less than a year, differ from informal caregivers of persons in subsequent stages of dementia. Differences will be investigated in (a) problems experienced in the provision of informal care, (b) the use of ambulatory types of professional support, and (c) the need for additional professional support. Results are based on a survey among 1494 Dutch informal caregivers. Almost all informal caregivers experience problems in caring for a person with dementia, irrespective of the stage of the illness process. Their main problems concern dealing with changes in the behaviour of the person with dementia and dreading the person's admission to a nursing home. Informal caregivers of persons who have had symptoms of dementia for a longer period of time (> 1 year) also experience limitations in their social network. Most persons with dementia receive some kind of professional support. Still, the majority of informal caregivers indicate a need for additional professional support, mainly concerning advice and information. Limiting the available support options for persons with initial symptoms of dementia and their informal caregivers is therefore undesirable. Considering the need for additional support in the initial stage of dementia as well as in subsequent stages, persons with dementia and their informal caregivers should be supported during the entire illness process.     

Rivastigmine als ondersteuning bij het dilemma van de behandeling van hallucinaties optredend bij ziekte van Parkinson

We report three cases of patients with Parkinson’s disease without dementia, admitted to our hospital because of hallucinations. The anti-Parkinson medication was adapted and the patients started with rivastigmine. As a result, hallucinations no longer occurred. A 79 years old man also required short-term quetiapine because of agitation and anti-Parkinson doses were without side effects, as a result of which mobility improved. An 84 years old woman reported mild side effects of rivastigmine, without consequences, whereas her mobility appeared to be good. A 72 years old woman reported mild memory problems upon admission, which improved during admission, as did her mobility after increasing the anti-Parkinson medication doses. Treatment of rivastigmine can be useful in the therapeutic dilemma in the treatment of hallucinations in patients with Parkinson’s disease (start anti-psychotic or reduce anti-Parkinson medication). In addition to adapting anti-Parkinson doses and sometimes short-term treating with an anti-psychotic, treatment with rivastigmine appears to be a quick improvement, without serious side effects. Also, mobility can improve, due to the possibility of increasing the anti-Parkinson doses, if necessary. Because of the many remaining questions, prospective randomised trials are needed.     

Bruikbaarheid en validiteit van de Nederlandse versie van de Montreal Cognitive Assessment (MoCA-D) bij het diagnosticeren van Mild Cognitive Impairment

Objective: The MoCA is a new screening test to detect Mild Cognitive Impairment (MCI). Purpose of this study is validating the Dutch version (MoCA-D). Method: We administered the MoCA-D to healthy control subjects and to elderly with MCI or dementia from a memory disorder outpatient clinic and a geriatric (outpatient) clinic (n=30, 32, 37 respectively, age≥60). Neuropsychological testing was part of the standard procedure for patients to diagnose MCI. Sensitivity, specificity and predictive values (positive: PPV and negative: NPV) of the MoCA-D were assessed. Results: A significant effect of group was found on MoCA-D total score (F(2,95)=67,9; p<0,01). With a cutoff score of d25, sensitivity and specificity to detect MCI in relation to healthy controls were 72% and 73%, respectively. PPV and NPV were 84% and 56%, respectively. With a cut-off score of d20, sensitivity to detect dementia in relation to MCI was 100% for severe dementia and 75% for mild dementia. Specificity for dementia was 81%, PPV 94% and NPV 55%. Conclusion: The MoCA-D distinguishes between healthy elderly, MCI patients and dementia patients. However, in this study, insufficient sensitivity and poor specificity were found. For the present, applying a broader and flexible screening procedure in order to detect MCI seems a more useful method than the interpretation of one test result in particular.     

Klinische presentatie van het chronisch subduraal hematoom bij ouderen

A 87-year old man was admitted to our hospital with decline in cognition and mobility and visual hallucinations. CT scanning revealed a bilateral chronic subdural hematoma. The hematoma was probably caused by a recent fall, while the patient was using acenocoumarol. Chronic subdural hematoma (CSDH) is a frequently occurring intracranial bleeding in the elderly. It usually occurs after a minor trauma and may present with a variety of symptoms. The differentiation between CSDH and other disorders like dementia can be difficult when the hematoma presents with cognitive decline and neuropsychiatic symptoms, such as hallucinations.     

Zin en onzin van eenzaamheidsinterventies bij ouderen

Loneliness interventions among older adults: Sense or nonsense? This article focuses on the most important findings of a unique evaluation study of loneliness interventions among older adults. Eighteen interventions have recently been carried out and closely monitored in various parts of the Netherlands. In ten of these interventions the number of participants was sufficiently large to quantitatively determine the effect of the intervention on loneliness. It does not appear to be easy to overcome loneliness: no more than two of the ten interventions resulted in a reduction in loneliness among participants that may be attributed to the intervention. Two other interventions may have had a preventive effect: whereas loneliness increased among members of the control group, it remained more or less constant over time among participants. The effect measurements were followed by process evaluations in an effort to gain insight into the possible reasons why feelings of loneliness were not alleviated among participants in the case of most of the interventions. This resulted in a number of lessons for the future, which may be used as a checklist when designing new interventions projects.Tijdschr Gerontol Geriatr 2007; 38: 186-218     

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     

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.