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OBJECTIVE: To determine the frequency and background of the use of assessment instruments for the Comprehensive Geriatric Assessment by clinical geriatricians and internists in geriatric medicine; the secondary aim was to make an inventory of the willingness to standardise the assessment instruments used. DESIGN: A descriptive questionnaire study. METHOD: In December 2016, we sent out a digital questionnaire (Survey Monkey) to all the hospitals in the Netherlands. Respondents were asked which instruments they used for specific domains of the Comprehensive Geriatric Assessment, what their choice of instruments was based on, if these instruments had added value, and if they were prepared to change the instruments they used. RESULTS: We received 66 responses (response: 82%). The most frequently-used instruments were: Mini Mental State Examination in combination with the clock drawing test (21%), Geriatric Depression Scale-15 (45%), Katz Index of Independence in Activities of Daily Living-6 (75%), Lawton and Brody (48%), Mini Nutritional Assessment(-short form) (outpatient; 56%) and Short Nutritional Assessment Questionnaire (inpatient: 36%), Experienced Burden Informal Care (46%), Charlson Comorbidity Index (35%), Timed Up and Go (76%), and the Safety Management System (VMS) fall risk question (21%). The most frequently used instruments were used in a large number of hospitals (35-97%).The variation of tests was the greatest in the domains of cognition, malnutrition, and mobility/physical functioning. Many respondents saw the added value of a consensus set of instruments (median: 70%; interquartile range (IQR): 50-86), and most were willing to change the instruments they use (median: 80%; IQR: 65-90). CONCLUSION: This inventory shows that the instruments used in most domains were reasonably uniform. Taking the willingness to change into account, a national set of basis instruments seems to be an achievable aim.

BACKGROUND: Different forms of case management for dementia have emerged over the past few years. In the COMPAS study (Collaborative dementia care for patients and caregivers study), two prominent Dutch case management forms were studied: the linkage and the integrated care form.AIM OF STUDY: Evaluation of the (cost)effectiveness of two dementia case management forms compared to usual care as well as factors that facilitated or impeded their implementation.METHODS: A mixed methods design with a) a prospective, observational controlled cohort study with 2 years follow-up among 521 dyads of people with dementia and their primary informal caregiver with and without case management; b) interviews with 22 stakeholders on facilitating and impeding factors of the implementation and continuity of the two case management models. Outcome measures were severity and frequency of behavioural problems (NPI) for the person with dementia and mental health complaints (GHQ-12) for the informal caregiver, total met and unmet care needs (CANE) and quality adjusted life years (QALYs).RESULTS: Outcomes showed a better quality of life of informal caregivers in the integrated model compared to the linkage model. Caregivers in the control group reported more care needs than those in both case management groups. The independence of the case management provider in the integrated model facilitated the implementation, while the rivalry between multiple providers in the linkage model impeded the implementation. The costs of care were lower in the linkage model (minus 22 %) and integrated care model (minus 33 %) compared to the control group.CONCLUSION: The integrated care form was (very) cost-effective in comparison with the linkage form or no case management. The integrated care form is easy to implement.

In particular in (very) old patients other comorbidities may cover symptoms evoked by polymyalgia rheumatica (PMR). By describing three different patients we show that the diagnosis PMR should be considered in the elderly when symptoms are atypical for those belonging to the comorbidity. PMR is an invalidating disease that rapidly reacts to prednisone. Doctors delay results in a later start with adequate treatment. Side effects of pain medication and loss of mobility can be prevented by starting early with adequate treatment

OBJECTIVE: To determine the predictive value of safety management system (VMS) screening questions for falling, delirium, and mortality, as punt down in the VMS theme 'Frail elderly'. DESIGN: Retrospective observational study. METHOD: We selected all patients ≥ 70 years who were admitted to non-ICU wards at the Deventer Hospital, the Netherlands, for at least 24 hours between 28 March 2011 and 10 June 2011. On admission, patients were screened with the VMS instrument by a researcher. Delirium and falls were recorded during hospitalisation. Six months after hospitalisation, data on mortality were collected. RESULTS: We included 688 patients with a median age of 78.7 (range: 70.0-97.1); 50.7% was male. The sensitivity of the screening for delirium risk was 82%, the specificity 62%. The sensitivity of the screening for risk of falling was 63%, the specificity 65%. Independent predictors for mortality within 6 months were delirium risk (odds ratio (OR): 2.3; 95% CI 1.1-3.2), malnutrition (OR: 2.1; 95% CI 1.3-3.5), admission to a non-surgical ward (OR: 3.0; 95% CI 1.8-5.1), and older age (OR: 1.1; 95%CI 1.0-1.1). Patients classified by the VMS theme 'Frail elderly' as having more risk factors had a higher risk of dying (p < 0.001). CONCLUSIONS: The VMS screening for delirium is a reasonably reliable instrument for identifying those elderly people with a high risk of developing this condition; the VMS sensitivity for fall risk is moderate. The number of positive VMS risk factors correlates with mortality and may therefore be regarded as a measure of frailty.

A multidisciplinary workgroup has revised the 2004 practice guidelines on 'Delirium' on the initiative of the Dutch Geriatrics Society. In comparison with the previous version, the new guidelines place more emphasis on screening and non-pharmaceutical prevention and treatment. They recommend a degree of restraint when prescribing medication. Both the patient's and the caregiver's perspectives are discussed. The guidelines also focus on delirium in patients in a nursing home setting, and describe what the workgroup regards as optimal care for patients suffering from delirium. The revised guidelines consider the diagnosis and treatment of delirium as a part of basic medical care and primarily the responsibility of the attending physician. The workgroup advises consulting an expert in the field of delirium only in cases of lack of experience, and for complex cases. The guidelines also include recommendations for the organization of follow-up care for the delirium patient

OBJECTIVES: To systematically identify and characterize prognostic models of mortality for older adults, their reported potential use, and the actual level of their (external) validity. DESIGN: The Scopus database until January 2010 was searched for articles that developed and validated new models or validated existing prognostic models of mortality or survival in older adults. SETTING: All domains of health care. PARTICIPANTS: Adults aged 50 and older. MEASUREMENTS: Study and model characteristics were summarized, including the model's development method and degree of validation, data types used, and outcomes. RESULTS: One hundred three articles describing 193 models in 10 domains and mostly originating from the United States were included. These domains were mostly secondary or tertiary care settings (54%) such as intensive care (7%) or geriatric units (8%). Half of the studies (50%) were not disease specific. Heart failure-related diseases (9%) and pneumonia (9%) constituted the major disease-specific subgroups. Most studies (67%) reported support of clinical individual (treatment) decisions as use of prognostic models, but only 34% were externally validated, and only four models (2%) were validated in more than two studies. Most studies (68%) developed at least one new model, but they did not often go beyond addressing their apparent validation (49%). CONCLUSION: Although prognostic models are regularly developed to support clinical individual decisions and could be useful for this purpose, their use is premature. Because clinical credibility and evidence of external validity build trust in prognostic models, both require much more consideration to enhance model acceptance in the future. J Am Geriatr Soc 59:1110-1115, 2011

The overall aim of this thesis was to improve primary care for community-dwelling older people in the Netherlands. First, by studying the effectiveness of multifactorial care on health and daily functioning of community-dwelling older people, second by exploring the value of the multifactorial care by investigating experiences of older people with this nurse-led multifactorial care, and third by assessing per capita healthcare costs of older people. We evaluated the effects of nurse-led multifactorial care in a cluster randomized controlled trial. 11 practices (n=1,209 participants) were randomized to the intervention group, 13 practices (n=1,074 participants) were randomized to the control group. We found no evidence that a one-year individualized multifactorial intervention program with nurse-led care coordination resulted in prevention or postponement of new disabilities in community-dwelling older people at increased risk of functional decline. One explanation might be that by conducting a comprehensive geriatric assessment many geriatric conditions were detected, yet resulted in low recognition rates of these geriatric conditions by older people themselves. Nevertheless, older people appreciated nurse-led multifactorial care, especially because of the feeling of being looked after. Hospitalization costs were the most important contributor to the overall healthcare costs of older people. Especially older people who encounter functional decline had the highest healthcare costs. Further studies should focus on shared decision making and collaboration with older people to improve overall quality of care.

This thesis addresses several aspects of health (loneliness, depression and cognition) and health assessment in older migrants. The overall objective of the thesis was to improve health diagnostics for older migrants, with the help of cross-culturally validated scales. The SYMBOL study (SYstematic Memory testing Beholding Other Languages) was a cross-sectional study in which particpants aged 55 years and older of Dutch, Turkish, Moroccan and Surinamese background were recruited via their GP’s. We cross-culturally validated scales, including a new dementia screening test, the Cross-Cultural Dementia screening (CCD), which could screen for dementia in migrants who speak little or no Dutch and have a low educational level. The results provided support for the use of the (translated version of the) De Jong Gierveld Loneliness Scale and the 15 item Geriatric Depression Scale among older Turkish, Moroccan, and Surinamese migrants as adequate assessment scales for loneliness and depression, respectively. In SYMBOL, we used the CCD to assess prevalence of mild cognitive impairment (MCI) and dementia in migrants with Turkish, Moroccan and Surinamese backgrounds. In Turkish, Moroccan and Surinamese‐Hindustani participants, MCI was 2-4 times more prevalent, and dementia was 3-4 times more prevalent compared to native Dutch. Knowing that these older migrant groups will increase, the need to address diseases which come with ageing will be larger and therefore research among older migrants has not come to an end. Researchers in Europe should integrate migrants in their study sample, as cross-culturally validated scales are available, to enlarge the body of scientific evidence.

Approximately 30% of people aged 65 and older suffer a fall each year; one in five of these falls will lead to significant injury. As the world’s ageing population increases, healthcare costs associated with falls are only expected to rise. It is estimated that over a third of falls may be preventable and evidence for causative, treatable factors is therefore essential. Cardiovascular disorders are among the several risk factors which have been identified to cause falls; in particular unexplained and recurrent falls. In part, this is due to the overlap between falls and syncope secondary to underlying cardiovascular disease. The main aim of this thesis was to study the association between cardiovascular conditions and falls, in particular cardiac arrhythmia, conduction abnormalities and structural abnormalities. Because these conditions could lead to falls via several pathways, another aim was to study potential mechanisms responsible for these associations. The results of this thesis show that several cardiovascular abnormalities are associated with falls in older adults, in particular atrial fibrillation, LV dysfunction, heart failure and low blood pressure. Furthermore, atrial fibrillation is associated with impaired mobility and greater drops in blood pressure on active stand, providing additional support for the framework in which cardiovascular abnormalities could lead to falls. Extending current fall preventive care with a cardiovascular evaluation and intervention is feasible, but randomized controlled trials investigating the effect of such an intervention on falls incidence are needed.

This thesis explores the role of information technology (IT) for prevention and management of falls in both general practice and hospital settings. Specifically, we address the question of how disease management concepts, process modeling, prognostic models and computerized decision support systems (CDSS) can contribute to a better management of falls shared by general practices, an emergency department and a geriatrics outpatient clinic. The thesis is organized in three parts addressing three research topics. The first topic regards the assessment of the current quality of care, including fall-related care, for the (vulnerable) elderly population. Our study shows that, although there has been much effort in improving the care for elderly patients in the last years, the reported quality of care according to the Assessing Care Of Vulnerable Elders (ACOVE) quality indicators (QIs) is still relatively low. The second topic is the analysis and improvement of the fall management process in an integrated care setting. This part relies on the concepts of disease-management and process modeling. The third topic is the quality of detection and management of falls in community dwelling elderly patients by general practitioners, and how to improve these by using computerized decision support systems. Although our results show that the quality of detection and management of falls in community dwelling elderly patients by general practitioners based on the fall-related ACOVE QIs is relatively low, our intervention showed that our non-intrusive CDSS that provided timely, patient-specific and proactive feedback was effective, at least in the short term, for better management of falls in primary care in terms of adherence to the QIs.

Serieuze adverse events als reanimatie, ongeplande IC-opname en (onverwacht) overlijden komen in de meeste gevallen niet onverwacht. In tachtig procent van deze patiënten zijn er tekenen van vitale dreiging, achteruitgang van de vitale parameters, te vinden in de 24 uur voorafgaand aan een dergelijk event. In 2008 werd door de inspectie het verplicht gesteld om een systeem in te voeren wat vitaal bedreigde patiënten eerder zou detecteren en management van deze patiëntengroep zou verbeteren. Hierbij werd het Spoed Interventie Systeem (SIS) aanbevolen. Op dat moment was er geen wetenschappelijk bewijs aanwezig voor de effectiviteit van dit systeem. In dit proefschrift wordt onderzocht of een SIS effectief is met behulp van een grote landelijke multicenter-studie, de COMET-studie. Na gefaseerde implementatie van Spoed Interventie Systemen in twaalf Nederlandse ziekenhuizen, waaraan ruim 166.000 patiënten hebben meegedaan, was er sprake van een significante daling van het aantal adverse events (sprake van een gecombineerd eindpunt) van ongeveer vijftien procent (OR 0.847, 95% CI 0.725-0.989). Daarbij was er zelfs een daling van het aantal reanimaties van bijna veertig procent (OR 0.607, 95% CI 0.393-0.937). In de andere artikelen van het proefschrift wordt stilgestaan bij de awareness van het zorgverlenend personeel rondom tijdige herkenning van vitaal bedreigde patiënten en daarnaast bij de mate waarin het systeem geïmplementeerd is. Naar aanleiding van de publicaties en specifiek de resultaten van de COMET-studie, kan de discussie binnen de wetenschappelijke wereld maar ook op maatschappelijk vlak worden ‘heropend’. Het niet-verplichte karakter alsmede de wijze van analyse van effectiviteit van het systeem kunnen nu beter worden bediscussieerd.

Veel van de huidige statistische modellen voor het voorspellen van overlevingskansen op de intensive care (ic) voldoen niet in de klinische praktijk. Dit komt doordat de modellen niet extern zijn gevalideerd en klinisch niet goed bruikbaar zijn. Lilian Minne onderzocht het gebruik van statistische modellen die voorspellen wat de overlevingskansen zijn van patiënten op de ic. Ze laat zien dat modellen snel verouderen vanwege veranderingen in de gezondheidszorg en de samenstelling van de patiëntenpopulatie. Hierdoor geven de modellen een inaccuraat beeld van de geleverde kwaliteit van zorg. Minne verbeterde de beschikbare modellen door de mate van orgaanfalen mee te wegen. Deze nieuwe modellen blijken net zo goed als het oordeel van artsen en zijn potentieel bruikbaar voor het ondersteunen van klinische beslissingen. Dit vereist wel uitgebreid onderzoek naar het besluitvormingsproces rondom levenseinde en de mogelijke impact van het gebruik van deze modellen in de klinische praktijk.