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Aims: To assess the impact of an oral healthcare program in nursing homes on the initial treatment backlog and residents' oral health stability., Materials and Methods: The study is a longitudinal cohort study in nursing home residents in Flanders, Belgium, to evaluate the oral healthcare programme Gerodent. The program consisted of: (1) the introduction of an oral healthcare team, (2) oral health education, (3) the implementation of oral health guidelines and protocols, and (4) regular visits of a mobile dental team. Data were extracted from the oral health records of 381 residents from 21 nursing homes who received treatments from the mobile dental team between October 2010 and March 2014 (mean follow-up period of 22.5 months). Oral health and treatment need between baseline and follow-up were compared., Results: The mean age at baseline was 82.4 years and the mean number of consultations per resident was 3.61 during the follow-up period. The proportion of residents with an oral treatment need was reduced from 65.9% to 31.3%. Among residents with natural teeth, there was significantly lower prevalence of caries (from 70.5% at baseline to 36.5% at follow-up; p<0.001), residual roots (from 54.2% to 25.1%; p<0.001), and need for fillings (from 31.9% to 17.1%; p<0.001) or extractions (from 64.3% to 31.6%; p<0.001). In the group with partial or full dentures (n = 223), 38.1% needed a repair, rebasing or renewal of their existing dentures at baseline and the respective figure at follow-up was 9.0% (p<0.001). In terms of oral health stability, 53% of the residents had no incident restorative and prosthetic treatment need throughout the follow-up period. A lower number of natural teeth at baseline (p<0.001) and a shorter follow-up period (p = 0.002) were associated with higher chances of oral health stability., Conclusion: The oral healthcare program Gerodent significantly reduced the treatment backlog and contributed to a considerable proportion of residents being stable in terms of oral health without any incident treatment needs., Competing Interests: The authors have declared that no competing interests exist.

Background: In the nursing home population, it is estimated that 1 in every 3 patients is polymedicated and given their considerable frailty, these patients are especially prone to adverse drug reactions. Clinical pharmacist-led medication reviews are considered successful interventions to improve medication safety in the inpatient setting. Due to the limited available evidence concerning the benefits of medication reviews performed in the nursing home setting, we propose a study aiming to demonstrate a positive effect that a clinical decision support system, as a health care intervention, may have on the target population. The primary objective of this study is to reduce the number of patients with at least one event when using the clinical decision support system compared to the regular care. These events consist of hospital referrals, delirium, falls, and/or deaths., Method/design: This study is a multicentre, prospective, randomised study with a cluster group design. The randomisation will be per main nursing home physician and stratified per ward (somatic and psychogeriatric). In the intervention group the clinical decision support system will be used to screen medication list, laboratory values and medical history in order to obtain potential clinical relevant remarks. The remarks will be sent to the main physician and feedback will be provided whether the advice was followed or not. In the control group regular care will be applied., Discussion: We strongly believe that by using a clinical decision support system, medication reviews are performed in a standardised way which leads to comparable results between patients. In addition, using a clinical decision support system eliminates the time factor to perform medication reviews as the major problems related to medication, laboratory values, indications and/or established patient characteristics will be directly available. In this way, and in order to make the medication review process complete, consultation within healthcare professionals and/or the patient itself will be time effective and the medication surveillance could be performed around the clock., Trial Registration: The Netherlands National Trial Register NTR5165 . Registered 2nd April 2015.

Introduction: The aim of this study is to examine the preparedness of Dutch municipalities (in terms of system readiness for innovation) for the challenges resulting from their new responsibilities under the long-term care reform of January 1, 2015., Methods: A qualitative research approach was used by conducting semi-structured interviews with representatives of nine Dutch municipalities responsible for the long-term care of older people in their respective municipalities., Results: Municipalities consider themselves to be largely prepared for their new responsibilities resulting from the long-term care reform. However, this perception mainly applies to practical changes (related to municipalities' organizational preparation for their new responsibilities) occurring in the short-term transition phase, not to the more long-term transformation phase., Conclusion: We argue that municipalities highly underestimate the long-term challenges that lie ahead of them (such as the development of a dedicated 'participation society') and, in fact, seem to fear the uncertainty of the consequences of these challenges., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To explore the impact of a supervised implementation of an oral healthcare protocol, in addition to education, on nurses' and nurses' aides' oral health-related knowledge and attitude., Materials and Methods: A random sample of 12 nursing homes, accommodating a total of 120-150 residents, was obtained using stratified cluster sampling with replacement. The intervention included the implementation of an oral healthcare protocol and three different educational stages. One of the investigators supervised the implementation process, supported by a dental hygienist. A 34-item questionnaire was developed and validated to evaluate the knowledge and attitude of nurses and nurses' aides at baseline and 6 months after the start of the intervention. Linear mixed-model analyses were performed to explore differences in knowledge and attitude at 6 months after implementation., Results: At baseline, no significant differences were observed between the intervention and the control group for both knowledge (p = 0.42) and attitude (p = 0.37). Six months after the start of the intervention, significant differences were found between the intervention and the control group for the variable knowledge in favour of the intervention group (p < 0.0001) but not for the variable attitude (p = 0.78). Out of the mixed model with attitude as the dependent variable, it can be concluded that age (p = 0.031), educational level (p = 0.009) and ward type (p = 0.014) have a significant effect. The mixed model with knowledge as the dependent variable resulted in a significant effect of the intervention (p = 0.001) and the educational level (p = 0.009)., Conclusion: The supervised implementation of an oral healthcare protocol significantly increased the knowledge of nurses and nurses' aides. In contrast, no significant improvements could be demonstrated in attitude., (© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd.)

Objective: To determine the prevalence of heart failure (HF) in nursing home residents and to gain insight into the clinical characteristics of residents with heart failure., Design: Multi-centre, observational, cross-sectional study., Method: 501 nursing home residents aged 65 years and over, in a department for chronic somatic diseases or a psychogeriatric department, participated in this study. The diagnosis of HF and the related characteristics were based on data collected from clinical examinations for heart failure (including history, physical examination, ECG, cardiac markers and echocardiography), patient records and questionnaires. A panel of two cardiologists and an internist-geriatrician made the final diagnosis of HF., Results: The prevalence of HF in nursing home residents was 33%. Dyspnoea, oedema and a history of cardiac disease were more common in residents with heart failure. Diabetes mellitus and chronic obstructive pulmonary disease also appeared to be more prevalent in this group. In 54% of the residents with HF, the diagnosis had not previously been made. Diagnosis of HF was not confirmed by the expert panel in 31% of residents with a history of HF., Conclusion: Heart failure does indeed appear to be very prevalent in nursing home residents. Heart failure had not been previously diagnosed in many cases but also a previous diagnosis of heart failure could be disproved in many participants. It is therefore important that the diagnostic process for heart failure in nursing home residents be improved.

Objectives: To establish the quality of medication reviews performed by nursing home physicians, general practitioners and pharmacists., Design and Setting: 15 Pharmacists, 13 general practitioners and 18 nursing home physicians performed a medication review for three cases (A, B and C), at three evaluation moments. First, they received the medication list. Secondly, they also received laboratory results and reason for admission and finally, we added medical history. Remarks were divided into 6 categories, i.e. indication without medication, medication without indication, contraindications/ interactions, dosage problems, double medication and wrong medication. Remarks were compared to the remarks made by our expert panel and scored according to our grading model as appropriate (0 to +3) or missed or potentially harmful (-1). For each medication error category, the percentage of participants who made this error was computed., Results: After the first evaluation moment, the overall estimated mean percentage score was -1.7% for case A, 3.9% for case B, and 8.7% for case C. After the second review, this score was 15.0% for case A, 19.8% for case B, and 22.2% for case C. This further increased to 30.0% for case A, 36.7% for case B and 44% for case C at the final evaluation. The absence of medication where there was an indication (indication without medication) was frequently missed and did not improve after adding the extra information regarding laboratory results, reason for admission and finally medical history., Conclusion: Increasing clinical information helps physicians and pharmacists to improve their medication reviews, however, additional information was still related with a high margin of error. Detection of certain errors becomes easier with additional information, whereas other errors remain undetected. To achieve a high standard of medication review, we have to change the way medication reviews should be performed.

Background & Aims: Many residents in European healthcare institutions are malnourished, with reported malnutrition prevalence rates of up to 60%. Due to the negative effects of malnutrition it is important to optimize the quality of nutritional care. If structural quality indicators of nutritional care might improve resident care and outcome is not yet known. The aim of this study is to explore whether structural quality indicators for nutritional care influence malnutrition prevalence in Dutch, German and Austrian nursing homes., Methods: This study follows a cross-sectional, multi-center design. Data were collected by using a standardised questionnaire at resident, ward and institution level., Results: Data from 214 nursing homes (NL = 133, G = 61, A = 20) were analysed. The prevalence of malnutrition varied significantly between the three countries (NL = 18.2% G = 20.1% A = 22.5%). Two structural quality indicators at ward level namely (1) the policy that the care file should include the nutritional intake for each patient and (2) having a weight measurement policy at ward level are predictive for malnutrition prevalence. Furthermore also the variable country was of influence., Conclusions: A policy of registering nutritional intake in the file of the patient and a policy to assess the patient's weight regularly have a positive influence on malnutrition prevalence., (Copyright © 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

The aim of this study was to measure the prevalence of (infected) chronic wounds in Dutch nursing homes and to explore which signs and symptoms are used to diagnose infected chronic wounds. Moreover, it was to determine which structural quality indicators related to chronic wound care at ward and institutional levels were fulfilled. In April 2012, as part of the annual National Prevalence Measurement of Care Problems of Maastricht University [Landelijke Prevalentiemeting Zorgproblemen (LPZ)], a multi-center cross-sectional point-prevalence measurement was carried out together with an assessment of relevant care quality indicators. The prevalence was 4·2%; 16 of 72 (22%) chronic wounds were considered to be infected. Increase of exudate (81·3%; n = 13), erythema (68·8%; n = 11), pain (56·3%; n = 9) and wound recalcitrance (56·3%; n = 9) were considered to be diagnostic signs and symptoms of a chronic wound infection. Although at institutional level most quality indicators were fulfilled, at ward level this was not the case. Despite the relatively low number of residents, we consider our population as representative for the nursing home population. It may be an advantage to appoint specific ward nurses and to provide them specifically with knowledge and skills concerning chronic wounds., (© 2013 The Authors. International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Purpose of the Study: The access process is an important first step in the long-term institutional care for older people. Access can be seen as a concept consisting of three closely related dimensions: availability, affordability and acceptability (three A's). This study takes a new perspective by investigating how older clients experience the access process., Design and Methods: Data were gathered through interviews with representatives of clients that were recently admitted in a long-term care facility, or if possible with clients themselves. A total of 33 respondents from 4 organizations that provide long-term institutional care were interviewed., Results: The first contact with the long-term care provider was made in several different ways. Finding a location nearby family was a common aim, which in urgent situations was not always feasible. Most respondents were satisfied about the process and felt taken care of personally. Yet, many respondents mention the lack of practical information and 'guidance' in the complexity of elder care. For acceptability, having a dedicated liaison in the organization was relevant., Implications: The study revealed that the 3A model can be used to understand how older clients or their representatives experience the operational access process to long-term care. Especially the dimensions' availability and acceptability seemed to shape their experience., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: Cardiac troponins T (cTnT) and I (cTnI) are the preferred biomarkers to detect myocardial damage. The present study explores the value of measuring cardiac troponins (cTn) in nursing home residents, by investigating its relation to heart failure and 1-year mortality using 1 cTnT and 2 cTnI assays that are widely used in clinical practice., Design: All participants underwent extensive clinical examinations and echocardiographic assessment for the diagnosis of heart failure. cTn was measured using high-sensitive (hs)- cTnT (Roche), hs-cTnI (Abbott), and sensitive cTnI (Beckman) assays. The glomerular filtration rate was estimated (eGFR) using serum creatinine and cystatin C concentrations. Data on all-cause mortality were collected at 1-year follow-up., Participants and Setting: Participants were 495 long-term nursing home residents, older than 65 years, of 5 Dutch nursing home organizations., Results: Median (IQR) concentrations were 20.6 (17.8-30.6), 6.8 (4.1-12.5), and 4.0 (2.0-8.0) ng/L for hs-cTnT, hs-cTnI, and cTnI, respectively. In total, 79% had elevated hs-cTnT concentrations, whereas only 9% and 5% of hs-cTnI and cTnI concentrations were elevated. Most important and independent determinants for higher hs-cTnT and hs-cTnI concentrations were heart failure and renal dysfunction. Whereas both heart failure (odds ratio [OR] 3.4) and eGFR lower than 60 mL/min/1.73 m(2) (OR 3.6) were equal contributors to higher hs-cTnT concentrations (all P < .001), hs-cTnI and cTnI were less associated with renal dysfunction (OR of, respectively, 1.9 and 2.1; P < .01) in comparison with heart failure (OR 4.3 and 4.7, respectively, P < .001). Furthermore, residents with higher hs-cTnT or hs-cTnI concentrations (fourth quartile) had respectively 4 versus 2 times more risk of 1-year mortality compared with lower concentrations., Conclusion: Regardless of their cardiac health, hs-cTnT but not hs-cTnI concentrations were elevated in almost all aged nursing home residents, questioning the use of the current diagnostic cutoff in elderly with high comorbidity. Nonetheless, measuring cardiac troponins, especially hs-cTnT, had a promising role in assessing future risk of mortality., (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To improve the current standalone pharmacy clinical decision support system (CDSS) by identifying and quantifying the benefits and limitations of the system., Methods: Alerts and handling of the executed clinical rules were extracted from the CDSS from the period September 2011 to December 2011. The number of executed clinical rule alerts, number of actions on alerts, and the reason why alerts were classified as not relevant were analyzed. The alerts where considered clinically relevant when the pharmacist needed to contact the physician., Results: The 4065 alerts have been separated into: 1137 (28.0%) new alerts, 2797 (68.8%) repeat alerts and 131 (3.2%) double alerts. When the alerts were analyzed, only 3.6% were considered clinically relevant. Reasons why alerts were considered as not to be relevant were: (a) the dosage was correct or already adjusted, (b) the drug was (temporarily) stopped and (c) the monitored laboratory value or drug dosage had already reverted to be within the reference limits. The reasons for no action were linked to three categorical limitations of the used system: 'algorithm alert criteria', 'CDSS optimization', and 'data delivery'., Conclusion: This study highlighted a number of ways in which the CDSS could be improved. These different aspects have been identified as important for developing an efficient CDSS., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: This study aimed to develop a practice guideline for a structured and consensus-based approach to relieve symptoms of pneumonia in patients with dementia in nursing homes., Methods: A five-round Delphi study involving a panel consisting of 24 experts was conducted. An initial version of the practice guideline was developed with leading representatives of Dutch University Medical Centers with a department for elderly care medicine, based on existing guidelines for palliative care. The experts evaluated the initial version, after which we identified topics that reflected the main divergences. The experts rated their agreement with statements that addressed the main divergences on a 5-point Likert scale. Consensus was determined according to pre-defined criteria. The practice guideline was then revised according to the final decisions made by the project group and the representatives., Results: The response rate for the expert panel was 67%. Main divergences included the applicability of guidelines for palliative care to patients with dementia and pneumonia in long-term care and the appropriateness of specific pharmacological treatment of dyspnea and coughing. Moderate consensus was reached for 80% of the statements. Major revisions included adding pharmacological treatment for coughing and recommending opioid rotation in the case of opioid-induced delirium. Two areas of divergent opinion remained: the usefulness of oxygen administration and treatment of rattling breath. The project group made the final decision in these areas., Conclusions: We developed a mostly consensus-based practice guideline for patients with dementia and pneumonia and mapped controversial issues for future investigation., (Copyright © 2014 John Wiley & Sons, Ltd.)

Pneumonia is a prevalent cause of death in care home residents. Dysphagia is a significant risk factor of aspiration pneumonia. The purpose of the current study was to screen for risk of aspiration in care home residents in the Netherlands and assess potential risk factors of aspiration. Five experienced speech-language therapists assessed 203 care home residents (115 primarily physically disabled, 88 primarily cognitively impaired) 60 and older in the first week after admission to a care home. In 43 (21.2%) residents, speech-language therapists assessed risk of aspiration and found no significant difference between physically disabled (26.1%) and cognitively impaired (14.8%) residents. After multivariate logistic regression analysis, the final prediction model for risk of aspiration showed Parkinson's disease as a significant factor (odds ratio = 5.11; 95% confidence interval [1.49, 17.52]) . The authors therefore conclude that risk of aspiration is a relevant care problem among Dutch care home residents and requires further assessment., (Copyright 2015, SLACK Incorporated.)

Objective: The aim of this study was to explore whether structural quality indicators for nutritional care influence malnutrition prevalence in the Netherlands, Germany, and Austria. Furthermore, differences in malnutrition prevalence and structural quality indicators for nutritional care nursing homes in the three countries were examined., Methods: This was a cross-sectional, multicenter study using a standardized questionnaire at the patient, ward, and institutional levels. Malnutrition was assessed by low body mass index, undesired weight loss, and reduced intake. Structural quality indicators of nutritional care were measured at the ward and institutional levels., Results: The prevalence of malnutrition differed significantly between the three countries (Netherlands 18%, Germany 20%, and Austria 22.7%). Structural quality indicators related to nutritional care as having a guideline of prevention and treatment of malnutrition were related to malnutrition and explained malnutrition prevalence variance between the Netherlands and Germany. Differences between the Netherlands and Austria in malnutrition prevalence still existed after controlling for these quality structural indicators., Conclusions: Structural quality indicators of nutritional care are important in explaining malnutrition variance between the Netherlands and Germany. However, they did not explain the difference in malnutrition prevalence between the Netherlands and Austria. Investigating the role of process indicators may provide insight in the role of structural quality indicators of nutritional care in explaining the malnutrition prevalence differences between the Netherlands and Austria., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Aims and Objectives: To examine the knowledge and use of pressure ulcer preventive measures among nursing staff in Dutch and German nursing homes., Background: Studies in the Netherlands and Germany have shown a large discrepancy in pressure ulcer prevalence rates among nursing homes in both countries and concluded that some of this variance could be explained by differences in pressure ulcer prevention., Design: A cross-sectional questionnaire survey nested in a prospective multicenter cohort study., Methods: A questionnaire was distributed to nursing staff employed in 10 Dutch nursing homes (n = 600) and 11 German nursing homes (n = 578). Data were collected in January 2009., Results: The response rate was 75·7% in the Netherlands (n = 454) and 48·4% in Germany (n = 283). Knowledge about useful pressure ulcer preventive measures was moderate in both countries, while nonuseful preventive measures were poorly known. On average, only 19·2% (the Netherlands) and 24·6% (Germany) of preventive measures were judged correctly as nonuseful. The same pattern could be seen with regard to the use of preventive measures, because nonuseful preventive measures were still commonly used according to the respondents., Conclusions: The results indicate that the respondents' knowledge and use of pressure ulcer preventive measures could be improved in both countries, especially for nonuseful measures. Changes and improvements can be achieved by providing sufficient education and refresher courses for nurses and nursing assistants employed within Dutch and German nursing homes., Relevance to Clinical Practice: Recurring education about pressure ulcer prevention is required among nursing staff employed in Dutch and German nursing homes, particularly in relation to the use of ineffective and outdated preventive measures. Obstacles regarding the implementation of preventive measures should be addressed to achieve a change in practice., (© 2013 John Wiley & Sons Ltd.)

Objectives: To investigate the malnutrition prevalence in Dutch care home residents with dementia over the years. Secondly, to examine the relationship of malnutrition and dementia and the role of care dependency and co-morbidity within this relationship., Design: This study is a secondary analysis of data of the annual independent Dutch National Prevalence Measurement of Care Problems of Maastricht University. The design involves a cross-sectional, multicenter point prevalence measurement., Setting: Care homes., Participants: 75399 residents older than 65 years (4523 resident with dementia) participated over 5 years (2006-2010). Sixty organizations measured 4 times, 31 organizations 3 times, 68 organizations 2 times, 511 organizations 1 time., Measurements: A standardized questionnaire was used to register amongst others data of weight, height, nutritional intake, undesired weight loss, comorbidity, dementia, and care dependency., Results: The study was able to show that there is a significant decline in malnutrition prevalence in the group of non-demented residents over the years (Non-demented group p <0.001). The prevalence of malnutrition in the demented group showed no significant reduction over the years. GEE analysis showed that malnutrition and dementia are related and that care dependency and age are important influencing factors in this relation., Conclusion: The results show that compared to the non-demented residents, the prevalence of malnutrition does not decline in demented care home residents over the years. Moreover, the findings of this study stress that malnutrition and dementia are related, while care dependency and age are confounding factors in this relationship.

Since 1998, the National Prevalence Measurement of Care Problems (LPZ) has annually measured the prevalence, prevention and treatment of a number of care problems in many health care organisations. These problems include pressure ulcers, incontinence, intertrigo, malnutrition, falls and the use of restraints. This article describes trends in the prevalence of these problems during the past few years and the preventive and treatment measures taken for clients residing in psychogeriatric and/or somatic wards of nursing homes. The results show that the prevalence of these care problems has declined in general. Nevertheless, the individual interventions (preventive measures and treatment) have not really changed in recent years. It is concluded that the extra attention paid to these care problems might already have had a positive effect on their prevalence. This must be further investigated. In any case, extra follow-up steps need to be taken to bring about a further decline. The article describes which steps the project group has already taken in this respect.

To determine the spread of Staphylococcus aureus within and between nursing home (NH) residents in the Euregion Meuse-Rhine, a cross-border region of the Netherlands and Germany, we investigated the prevalence of antibiotic resistance, genetic background and population structure of both methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) isolates. A total of 245 S. aureus isolates were collected from NH residents. Susceptibility testing was performed with microbroth dilution. The genetic background was determined using spa typing, SCCmec typing, pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Differences in the prevalence of resistance between the German and Dutch MSSA isolates were observed for the macrolides (15 % vs. 2 %, p = 0.003), clindamycin (15 % vs. 0 %, p = 0.003) and ciprofloxacin (34 % vs. 25 %). The macrolide and ciprofloxacin resistance varied between the NHs, while trimethoprim-sulfamethoxazole resistance was low in all residents. The MRSA prevalence was 3.5 % and <1 % among the German and Dutch NH residents, respectively (p = 0.005). The German MRSAs, isolated in 7 out of 10 NHs, belonged to ST22-MRSA-IV or ST225-MRSA-II. spa clonal complexes (spa-CCs) 015 and 002 were prevalent among the German MSSA isolates and spa-CCs 024 and 1716 were prevalent among the Dutch MSSA isolates. The antibiotic resistance of MSSA and the MRSA prevalence were significantly higher among the German NH residents. The spread of two MRSA clones was observed within and between the German NHs, but not between the Dutch and German NHs. Differences in the prevalence of resistance and the prevalence of MRSA between NHs on both sides of the border warrant the continuation of surveillance at a local level.

The frail elderly populations of nursing homes frequently use drugs and suffer from considerable comorbidities. Medication reviews are intended to support evidence based prescribing and optimise therapy. However, literature is still ambiguous regarding the optimal method and the effects of medication reviews. Innovative computerised systems may support the medication reviews in the future. We are developing a clinical decision support system (CDSS) that, independently of the prescribing software, continuously monitors all prescribed drugs while taking into account co-medication, laboratory-data and co-morbidities. The CDSS will be developed in five phases: (1) development of the computerised system, (2) development of the clinical rules, (3) validation of the CDSS, (4) randomised controlled trial, and (5) feasibility for implementation in different nursing homes. The clinical decision support system aims at supporting the traditional medication review.

Objectives: To investigate whether the incidence of pressure ulcers in nursing homes in the Netherlands and Germany differs and, if so, to identify resident-related risk factors, nursing-related interventions, and structural factors associated with pressure ulcer development in nursing home residents., Design: A prospective multicenter cohort study., Setting: Ten nursing homes in the Netherlands and 11 nursing homes in Germany (around Berlin and Brandenburg)., Participants: A total of 547 newly admitted nursing home residents, of which 240 were Dutch and 307 were German. Residents had an expected length of stay of 12 weeks or longer., Measurements: Data were collected for each resident over a 12-week period and included resident characteristics (eg, demographics, medical history, Braden scale scores, nutritional factors), pressure ulcer prevention and treatment characteristics, staffing ratios and other structural nursing home characteristics, and outcome (pressure ulcer development during the study). Data were obtained by trained research assistants., Results: A significantly higher pressure ulcer incidence rate was found for the Dutch nursing homes (33.3%) compared with the German nursing homes (14.3%). Six factors that explain the difference in pressure ulcer incidence rates were identified: dementia, analgesics use, the use of transfer aids, repositioning the residents, the availability of a tissue viability nurse on the ward, and regular internal quality controls in the nursing home., Conclusion: The pressure ulcer incidence was significantly higher in Dutch nursing homes than in German nursing homes. Factors related to residents, nursing care and structure explain this difference in incidence rates. Continuous attention to pressure ulcer care is important for all health care settings and countries, but Dutch nursing homes especially should pay more attention to repositioning residents, the necessity and correct use of transfer aids, the necessity of analgesics use, the tasks of the tissue viability nurse, and the performance of regular internal quality controls., (Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: The objective of this study was to assess the effectiveness of a supervised implementation of the "Oral health care Guideline for Older people in Long-term care Institutions" (OGOLI) in The Netherlands., Materials and Methods: A sample of 12 care homes in the Netherlands was allocated randomly to an intervention or control group. While the residents in the control group received oral health care as before, the intervention consisted of a supervised implementation of the OGOLI., Results: At baseline, the overall random sample comprised 342 residents, 52 % in the intervention group and 48 % in the control group. At 6 months, significant differences were observed between the intervention and the control group for mean dental as well as denture plaque, with a beneficial effect for the intervention group. The multilevel mixed-model analyses conducted with the plaque scores at 6 months as outcome variables showed that the reduction by the intervention was only significant for denture plaque., Conclusions: Supervised implementation of the OGOLI was more effective than non-supervised implementation in terms of reducing mean plaque scores at 6 months. However, the multilevel mixed-model analysis could not exclusively explain the reduction of mean dental plaque scores by the intervention., Clinical Relevance: A supervised implementation of an oral health care guideline improves oral health of care home residents.

Objectives: Empiric antibiotic treatment should be based on recent surveillance data. Therefore, we conducted a surveillance of (multidrug) resistance of Escherichia coli and antibiotic use among Dutch nursing home (NH) residents. Pulsed-field gel electrophoresis and multilocus sequence typing were used to describe the spread of multidrug-resistant strains., Design: Observational study., Setting: Five NHs in the southern part of The Netherlands., Participants: A total of 337 NH residents from both somatic and psychogeriatric wards., Measurements: The prevalence and spread of antibiotic resistance and multidrug resistant E. coli isolates collected from urine samples and antibiotic use among the NH residents were investigated., Results: A total of 208 E. coli isolates were collected from 308 urine samples. Resistance to amoxicillin-clavulanic acid was 23% and resistance to ciprofloxacin was 16%. Resistance to trimethoprim-sulfamethoxazole was 19%, whereas nitrofurantoin resistance was less than 1%. Multidrug resistance was observed in 28 of the 208 isolates (13%). Several isolates showed a similar pulsed-field gel electrophoresis pulsotype and multilocus sequence typing type. Sequence type (ST) 131 was the most prevalent (48%) and was demonstrated in all NHs and with four different pulsotypes. Consumption of antibiotics for systemic use was 64.4 defined daily dose (DDD)/1000 residents/day. Amoxicillin-clavulanic acid was most frequently prescribed (20.92 DDD/1000 residents/day), followed by the quinolones (14.8 DDD/1000 residents/day)., Conclusion: We observed a high prevalence of antibiotic resistance and antibiotic use. In particular, the use of and resistance to fluoroquinolones is concerning. Because of the high prevalence of resistance, many agents are no longer suitable for empiric treatment. E. coli ST131, which has also been demonstrated in this study, poses a potential risk to this vulnerable population. We have clearly demonstrated that the resistance among NH residents is different from elderly living at home and hospitalized patients, and with the emergence of resistant strains, such as ST131, NHs are a potential reservoir for multidrug resistant bacteria., (Copyright © 2013. Published by Elsevier Inc.)

A growing number of older people have teeth, which are vulnerable to oral diseases. To maintain good oral health, an adequate amount of saliva should be secreted and the saliva should possess adequate buffer capacity. The study aim was to investigate the associations of saliva secretion rate and acidity with gender, age, and some medical characteristics in a convenience sample of physically disabled older care home residents. In 20 male and 30 female physically disabled older care home residents with a mean age of 78.1 ± 9.7 years, the resting, chewing-stimulated, and acid-stimulated whole saliva secretion rate and acidity, as well as the main medical diagnosis and the number of medications used, were registered. Resting, chewing-stimulated and acid-stimulated whole saliva secretion rates were lower in women than in men and negatively associated with age and the number of medications used. In female residents, the acidity of acid-stimulated whole saliva was negatively associated with the acid-stimulated whole saliva secretion rate. In residents aged >70 years, the acidity of resting whole saliva was positively associated with age. The acidity of acid-stimulated whole saliva of all residents was positively associated with the number of medications used.

Background: Stroke is one of the major causes of loss of independence, decreased quality of life and mortality among elderly people. About half of the elderly stroke patients discharged after rehabilitation in a nursing home still experience serious impairments in daily functioning one year post stroke, which can lead to difficulties in picking up and managing their social life. The aim of this study is to evaluate the effectiveness and feasibility of a new multidisciplinary transmural rehabilitation programme for older stroke patients., Methods: A two group multicentre randomised controlled trial is used to evaluate the effects of the rehabilitation programme. The programme consists of three care modules: 1) neurorehabilitation treatment for elderly stroke patients; 2) empowerment training for patient and informal caregiver; and 3) stroke education for patient and informal caregiver. The total programme has a duration of between two and six months, depending on the individual problems of the patient and informal caregiver. The control group receives usual care in the nursing home and after discharge. Patients aged 65 years and over are eligible for study participation when they are admitted to a geriatric rehabilitation unit in a nursing home due to a recent stroke and are expected to be able to return to their original home environment after discharge. Data are gathered by face-to-face interviews, self-administered questionnaires, focus groups and registration forms. Primary outcomes for patients are activity level after stroke, functional dependence, perceived quality of life and social participation. Outcomes for informal caregivers are perceived care burden, objective care burden, quality of life and perceived health. Outcome measures of the process evaluation are implementation fidelity, programme deliverance and the opinion of the stroke professionals, patients and informal caregivers about the programme. Outcome measures of the economic evaluation are the healthcare utilisation and associated costs. Data are collected at baseline, and after six and 12 months. The first results of the study will be expected in 2014., Trial Registration: International Standard Randomised Controlled Trial Register Number ISRCTN62286281, The Dutch Trial Register NTR2412.

Objective: The aim of this study was to describe and compare structural and process indicators of nutritional care in Austrian hospitals and nursing homes., Methods: A multicenter, cross-sectional study was performed using a standardized and tested questionnaire. Data were collected on patient and institutional levels of hospitals and nursing homes., Results: Data from 18 Austrian hospitals (n = 2326 patients) and 18 Austrian nursing homes (n = 1487 residents) were collected. The prevalence of malnutrition was 23.2% in hospitals and 26.2% in nursing homes. All hospitals and 83.3% of the nursing homes employed dietitians. Guidelines for the prevention and treatment of malnutrition were used infrequently. Nutritional screening at admission was performed in 62.6% of the hospitalized patients and 93.4% of the nursing home residents. Nutritional screening tools were used in 28.9% of the nursing home residents and 14.5% of the hospitalized patients. Oral nutritional support was preferred to enteral and parenteral nutrition in the two settings. Dietitians were consulted in 27.5% of the malnourished hospitalized patients and 74.7% of the malnourished nursing home residents., Conclusion: The study demonstrated that nursing homes fulfilled more structural indicators and performed nutritional screening at admission more often than hospitals. Nevertheless, the prevalence of malnutrition was high in the two settings and a substantial number of malnourished patients/residents received no nutritional intervention at all. These results show the necessity for improvements in the nutritional care in Austria, for instance, through the routine use of nutritional screening tools followed by tailored nutritional interventions in patients/residents in need., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Heart failure is likely to be particularly prevalent in the nursing home population, but reliable data about the prevalence of heart failure in nursing homes are lacking. Therefore the aims of this study are to investigate (a) the prevalence and management of heart failure in nursing home residents and (b) the relation between heart failure and care dependency as well as heart failure and quality of life in nursing home residents., Methods/design: Nursing home residents in the southern part of the Netherlands, aged over 65 years and receiving long-term somatic or psychogeriatric care will be included in the study. A panel of two cardiologists and a geriatrician will diagnose heart failure based on data collected from actual clinical examinations (including history, physical examination, ECG, cardiac markers and echocardiography), patient records and questionnaires. Care dependency will be measured using the Care Dependency Scale. To measure the quality of life of the participating residents, the Qualidem will be used for psychogeriatric residents and the SF-12 and VAS for somatic residents., Conclusion: The study will provide an insight into the actual prevalence and management of heart failure in nursing home residents as well as their quality of life and care dependency., Trial Registration: Dutch trial register NTR2663.

Objectives: The aim of this study was to provide an insight into burnout and mental health problems of professional caregivers working in traditional and small-scale long term care settings for elderly residents with dementia in the Netherlands and Belgium., Design: This study was part of a larger study investigating similarities and differences between traditional and small-scale long term care settings for elderly residents with dementia. In this article, the perspective of the professional caregiver is of central importance. A survey was conducted among professional caregivers of residents with dementia, older than 65 years, at 2 measurement moments (at baseline and after 12 months)., Setting: The questionnaire was administered to professionals working in traditional and small-scale long term care settings in the Netherlands and Belgium., Participants: Professional caregivers (n = 80) working in 5 different care settings completed a questionnaire., Measurements: The questionnaire included items on personal data, mental health problems (GHQ-12), and burnout (UBOS-C, divided into emotional exhaustion, depersonalization, and personal accomplishment). Analyses were conducted using Mixed Models analysis., Results: Although mental health problems and emotional strain increased significantly over time in both types of settings and countries, overall levels of health problems and burnout were low. As regards emotional strain, professional caregivers in small-scale living facilities showed significantly increased levels in comparison with traditional units. Two significant differences between the countries were also found, with less "depersonalization" and more "personal accomplishment" in Dutch settings compared with Belgian settings. No differences emerged for type of setting or over time on "depersonalization" and "personal accomplishment." The analyses were controlled for age, sex, educational level, and work experience in dementia care, but did not yield significant effects., Conclusion: Owing to cutbacks in expenditure, the growing number of people with dementia, and the heavier workload, the working environment will become increasingly challenging. Future research should focus on training professional caregivers working in long term care settings how to maximize the quality of client interaction while keeping burnout and mental health problems to a minimum., (Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Backgrounds & Aims: Malnutrition in western health care involves a tremendous burden of illness. In this study the economic implications of malnutrition in Dutch nursing homes are investigated as part of the Health and Economic Impact of Malnutrition in Europe Study from the European Nutrition for Health Alliance., Methods: A questionnaire was developed, focussing on the additional time and resources spent to execute all relevant nutritional activities in nursing home patients with at risk of malnutrition or malnourished. Results were extrapolated on national level, based on the prevalence rates gathered within the national Prevalence Measurement of Care Problems 2009., Results: The normal nutritional costs are 319 million Euro per year. The total additional costs of managing the problem of malnutrition in Dutch nursing homes involve 279 million Euro per year and are related to extra efforts in nutritional screening, monitoring and treatment. The extra costs for managing nursing home residents at risk of malnutrition are 8000 euro per patient and 10000 euro for malnourished patients., Conclusions: The extra costs related to malnutrition are a considerable burden for the nursing home sector and urge for preventive measures., (Crown Copyright © 2011. Published by Elsevier Ltd. All rights reserved.)

Objective: Systematic reviews suggest that mental practice as an additional therapy for people with stroke might be effective and suggest that more trials with better defined interventions are needed. This study investigated whether imagining the skilled movement systematically can contribute to a quicker and/or better recovery of stroke patients in long term care., Design: A multicenter randomized controlled trial., Setting: Dutch nursing homes., Participants: Stroke patients in the subacute phase of recovery., Interventions: Study participants were randomly assigned to the control or experimental group. Over a 6-week intervention period, both groups received multi professional therapy as usual. Additionally, patients in the experimental group had instruction on mental practice with a 4-step framework embedded in regular therapy time., Main Outcome: Outcomes were assessed at 6 weeks and 6 months with the patient-perceived effect on performance of daily activities (10-point Numeric Rating Scale). Six secondary outcomes on impairment and activity level were also assessed. Primary analyses were performed according to the intention-to-treat principle. Generalized estimating equations (GEE) were used to analyze effects., Results: Thirty-six adult stroke patients (average age 77.8, ± 7.2 years) participated in the trial. No effect in favor of the mental practice intervention on any outcome measure could be detected at either measuring points., Conclusions: This study could not show differences between embedded mental practice and current standard of care. However, stroke pathways in Dutch nursing homes select specific and frail patients, which might have reduced the effects of training., (Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Institutionalized older people are prone to oral health problems and their negative impact due to frailty, disabilities, multi-morbidity, and multiple medication use. Until recently, no evidence-based oral health care guideline for institutionalized older people has been available. For that reason, the Dutch Association of Nursing Home Physicians developed the Oral health care Guideline for Older people in Long-term care Institutions (OGOLI), meeting the requirements of the AGREE instrument for assessing a guideline's quality. This short report presents the keynotes and the content of the Oral health care Guideline. Most recommendations are based on expert opinions. Only 4 recommendations (education, pneumonia, use of an electric toothbrush, and fluoride rinsing in case of a sudden increase of oral plaque amount) are based on evidence level A2 conclusions. This emphasizes the need for further research on oral health of institutionalized older people., (© 2011 The Gerodontology Society and John Wiley & Sons A/S.)

Objectives: To explore the long-term effects of the implementation of an oral hygiene protocol in nursing homes., Methods: Out of 14 nursing homes (Flanders) seven nursing homes were randomly allocated to the intervention group and confirmed to implement an 'oral hygiene protocol'. The remaining nursing homes (the control group) continued to perform oral hygiene as usual. Oral hygiene levels were scored and factors related to plaque levels were recorded. Mixed model analysis with random institution effect, were performed to explore differences in oral hygiene levels owing to the intervention, and the predictive value of explanatory variables., Results: At baseline, no significant differences were found between plaque levels in both study groups. In an unadjusted analysis, different effects were observed on denture and dental plaque. The lowest denture plaque levels were found 2 years after the start of the study, while the lowest dental plaque levels were found at the end of the study. The effect of the intervention could not be confirmed in an adjusted mixed model, where significant indicators for dental plaque were resident's dependency (P<0.01) and presence of mouth rinse (P<0.01). Capacity of the nursing home (P<0.05) and the presence of toothpaste (P<0.01) were dominant influencing factors for denture plaque., Conclusions: After 5 years of implementation obtained plaque levels were unsatisfactory. A lot of uncertainties remained on the impact of characteristics of individual nursing homes. Obtaining adequate oral hygiene levels in nursing homes remain an important ongoing challenge and needs further research., (© 2011 John Wiley & Sons A/S.)

Aims and Objectives: This study investigates possible differences in malnutrition prevalence rates in Dutch and German nursing homes. It seeks to provide insight into the screening, prevention and treatment of malnutrition and the indicators for nutritional care policy., Background: For decades, malnutrition has been an important problem in health care settings worldwide. A considerable percentage of frail older people suffer from malnutrition. In European nursing homes, the reported prevalence rates range widely (2% to 85%)., Method: This is a multicentre, cross-sectional prevalence study of malnutrition in Dutch and German nursing homes using standardised methodology, with the participation of respectively 5848 and 4923 residents (65+ years)., Results: Patient characteristics differed significantly between the two countries. Dutch residents were more often male, younger, more care-dependent and significantly more at risk of malnutrition (31·7%). However, overall malnutrition prevalence rates did not differ significantly (Netherlands 26·8% and Germany 26·5%). All German residents were screened at admission, whereas only 73·1% of the Dutch residents were. As part of screening, nutritional screening tools were used in 38·0% of Dutch and 42·1% of the German residents. A dietician was consulted for 36·7% Dutch and 9·3% German malnourished residents. The proportion of malnourished receiving nutritional intervention was larger in Germany than in the Netherlands. Structural indicators for nutritional policy were fulfilled more often in the Netherlands care at institutional level whereas in Germany they were fulfilled more often at ward level., Conclusion: In this study, German residents had a somewhat better nutritional status than Dutch residents and more is done to enhance nutritional status in German nursing homes. The differences would be somewhat larger if both populations were more comparable., Relevance to Clinical Practice: Comparing malnutrition prevalence rates, prevention and interventions in health care institutions and countries gives insight into international differences in quality of care., (© 2011 Blackwell Publishing Ltd.)

Rationale, Aims and Objectives: Annual national prevalence surveys have been conducted in the Netherlands over the past 10 years and have revealed high prevalence rates in Dutch nursing homes. Pressure ulcer guideline implementation is one of the factors that can influence prevalence rates. Previous research has shown that these guidelines are often only partly implemented in Dutch nursing homes. Reasons for this lack of pressure ulcer guideline implementation are not known. Therefore, the aim of this study is to investigate the current situation regarding pressure ulcer guideline dissemination and implementation in Dutch nursing homes., Methods: Semi-structured interviews were conducted in eight nursing homes in the Netherlands from January till December 2008. In each nursing home, interviews were held with eight persons., Results: The implementation of pressure ulcer guidelines was lacking in some of the nursing homes. Risk assessment scales were often not used in practice, repositioning schemes were not always available and, when they were, they were often not used in practice. Knowledge about guideline recommendations was also lacking and pressure ulcer education was inadequate. Barriers to applying guideline recommendations in practice were mostly related to personnel and communication., Conclusions: The implementation of pressure ulcer guidelines does not seem to be successful in all nursing homes and needs more attention. Barriers mentioned by the interviewees in applying guideline recommendations need to be addressed. Providing adequate education for nursing home staff and increasing attention for pressure ulcer care can be the first steps in improving the implementation of pressure ulcer guidelines., (© 2010 Blackwell Publishing Ltd.)

Background: The increase in the number of people with dementia will lead to greater demand for residential care. Currently, large nursing homes are trying to transform their traditional care for residents with dementia to a more home-like approach, by developing small-scale living facilities. It is often assumed that small-scale living will improve the quality of life of residents with dementia. However, little scientific evidence is currently available to test this. The following research question is addressed in this study: Which (combination of) changes in elements affects (different dimensions of) the quality of life of elderly residents with dementia in long-term care settings over the course of one year?, Methods/design: A longitudinal comparative study in traditional and small-scale long-term care settings, which follows a quasi-experimental design, will be carried out in Belgium and the Netherlands. To answer the research question, a model has been developed which incorporates relevant elements influencing quality of life in long-term care settings. Validated instruments will be used to evaluate the role of these elements, divided into environmental characteristics (country, type of ward, group size and nursing staff); basic personal characteristics (age, sex, cognitive decline, weight and activities of daily living); behavioural characteristics (behavioural problems and depression); behavioural interventions (use of restraints and use of psychotropic medication); and social interaction (social engagement and visiting frequency of relatives). The main outcome measure for residents in the model is quality of life. Data are collected at baseline, after six and twelve months, from residents living in either small-scale or traditional care settings., Discussion: The results of this study will provide an insight into the determinants of quality of life for people with dementia living in traditional and small-scale long-term care settings in Belgium and the Netherlands. Possible relevant strengths and weaknesses of the study are discussed in this article., Trial Registration: ISRCTN: ISRCTN23772945.

Moral case deliberation (MCD) is a specific form of clinical ethics, aiming to stimulate ethical reflection in daily practice in order to improve the quality of care. This article focuses on the implementation of MCD in nursing homes and the questions how and where to organize MCD. The purpose of this study was to evaluate one way of organizing MCD in two Dutch nursing homes. In both of these nursing homes the MCD groups had a heterogeneous composition and were organized apart from existing institutional communication structures. As part of a naturalistic evaluation, systematic observations, interviews and focus groups were completed. The findings indicate that the heterogeneous composition and MCD meetings separate from existing structures have benefits. However, the participants also reported negative experiences. This gives rise to the question whether a mixed MCD group which meets separately is an effective way to embed MCD as an instrument for reflection on moral issues in daily practice. We conclude that there is no single answer to that question. In the end, the two implementation strategies (i.e. within existing communication structures and a mixed MCD group) can be complementary to each other., (© The Author(s) 2011)

Background: As the incidence of stroke has increased, its impact on society has increased accordingly, while it continues to have a major impact on the individual. New strategies to further improve the quality, efficiency and logistics of stroke services are necessary. Early discharge from hospital to a nursing home with an adequate rehabilitation programme could help to optimise integrated care for stroke patients.The objective is to describe the design of a non-randomised comparative study evaluating early admission to a nursing home, with multidisciplinary assessment, for stroke patients. The study is comprised of an effect evaluation, an economic evaluation and a process evaluation., Methods/design: The design involves a non-randomised comparative trial for two groups. Participants are followed for 6 months from the time of stroke. The intervention consists of a redesigned care pathway for stroke patients. In this care pathway, patients are discharged from hospital to a nursing home within 5 days, in comparison with 12 days in the usual situation. In the nursing home a structured assessment takes place, aimed at planning adequate rehabilitation. People in the control group receive the usual care. The main outcome measures of the effect evaluation are quality of life and daily functioning. In addition, an economic evaluation will be performed from a societal perspective. A process evaluation will be carried out to evaluate the feasibility of the intervention as well as the experiences and opinions of patients and professionals., Discussion: The results of this study will provide information about the cost effectiveness of the intervention and its effects on clinical outcomes and quality of life. Relevant strengths and weaknesses of the study are addressed in this article., Trial Registration: Current Controlled Trails ISRCTN58135104.

Introduction: Heart failure is an important problem in western countries. In nursing home residents heart failure is expected to be highly prevalent. However, accurate diagnosis of heart failure in these patients is often hampered due to atypical findings and concomitant co-morbidity. In order to deliver adequate nursing care and medical treatment, it is important to get insight into the prevalence of heart failure in this target group of patients., Objectives: To assess the prevalence of heart failure as well as the co-morbidity interfering with heart failure in nursing home residents., Methods and Results: A systematic literature review was conducted in Medline, Embase, Cinahl and the Cochrane Library. Ten studies were ultimately included. Findings indicate that the mean prevalence of heart failure is 20% (range 15-45%) and that there is a significant level of co-morbidity (dementia, diabetes mellitus and chronic obstructive pulmonary disease) in nursing home residents with heart failure., Conclusion: The reported prevalence of heart failure in nursing home residents is higher than in the general population and is associated with considerably co-morbidity. However there are also indications that the prevalence of heart failure in nursing home residents is underestimated, negatively affecting quality of life and quality of care. Therefore, prospective prevalence studies and studies aiming to improve the care for nursing home residents with heart failure are warranted.

Background: Nursing home residents needing both psychiatric care and nursing home care for either somatic illness or dementia combined with psychiatric disorders or severe behavioural problems are referred to as Double Care Demanding patients, or DCD patients. Integrated models of care seem to be necessary in order to improve the well-being of these residents., Objectives: Two research questions were addressed. First, which integrated interventions combining both psychiatric care and nursing home care in DCD nursing home residents are described in the research literature? And second, which outcomes of integrated interventions combining both psychiatric care and nursing home care in DCD nursing home residents are reported in the literature?, Method: A critical review of studies was done that involved integrated interventions combining both psychiatric care and nursing home care on psychiatric disorders and severe behavioural problems in nursing home patients. A systematic literature search was performed in a number of international databases., Results: Eight intervention trials, including four RCTs (2b level of evidence), were identified as relevant studies for the purpose of this review. Seven studies, three of which were RCTs, showed beneficial effects of a comprehensive, integrated multidisciplinary approach combining medical, psychiatric and nursing interventions on severe behavioural problems in DCD nursing home patients., Conclusions: Important elements of a successful treatment strategy for DCD nursing home patients include a thorough assessment of psychiatric, medical and environmental causes as well as programmes for teaching behavioural management skills to nurses. DCD nursing home patients were found to benefit from short-term mental hospital admission.This review underlines the need for more rigorously designed studies to assess the effects of a comprehensive, integrated multidisciplinary approach towards DCD nursing home residents., ((c) 2009 John Wiley & Sons, Ltd.)

Objective: In most health care organizations there is still insufficient awareness for recognizing and treating malnourished patients. To gain more insight into nutritional care policies in Dutch health care organizations, this study investigated screening, treatment, and other quality indicators of nutritional care., Methods: In 2007 a cross-sectional multicenter study was performed that included 20 255 patients (hospitals, n = 6021; nursing homes, n = 11 902; home care, n = 2332). A standardized questionnaire was used to study nutritional screening and treatment at the patient level and quality indicators at institutional and ward levels (e.g., malnutrition guidelines/protocols, nutritional education, and weighing policy)., Results: Nutritional screening was performed more often in nursing homes (60.2%) than in hospitals (40.3%) and home care (13.9%, P < 0.001). In general, one in every five patients was malnourished, and nutritional treatment was applied in fewer than 50% of all malnourished patients in nursing homes, hospitals, and home care. At ward level nursing homes focused more on the quality of nutritional care than did hospitals and home care, especially with respect to controlling the use of nutritional guidelines (54.6%, P < 0.03), weighing at admission (82.9%, P < 0.01), and mealtime ambiance (91.8%, P < 0.01)., Conclusion: This large-scale study shows that malnutrition is still a considerable problem in one of every five patients in all participating health care settings. It furthermore demonstrates that recognizing and treating malnutrition continues to be problematic. To target the problem of malnutrition adequately, more awareness is needed of the importance of nutritional screening, appropriate treatment, and other nutritional quality indicators.

Objective: to evaluate the effectiveness of a multifactorial intervention on incidence of falls in psychogeriatric nursing home patients., Design: cluster-randomised controlled 12-month trial., Setting: psychogeriatric wards in 12 nursing homes in The Netherlands., Participants: psychogeriatric nursing home patients (n = 518)., Intervention: a general medical assessment and an additional specific fall risk evaluation tool, applied by a multidisciplinary fall prevention team, resulting in general and individual fall prevention activities., Measurements: falls., Results: there were 355 falls in 169.5 patient-years (2.09 falls per patient per year) in the intervention group and 422 falls in 166.3 patient-years (2.54 falls per patient per year) in the control group. Intention-to-treat analysis with adjustment for ward-related and patient-related parameters, and intra-cluster correlation, showed that the intervention group had a significantly lower mean fall incidence rate than the control group (rate ratio = 0.64, 95% CI = 0.43-0.96, P = 0.029). Subgroup analyses showed that fall risk declined further as patients participated longer in the intervention programme., Conclusion: the introduction of a structured multifactorial intervention to prevent falls in psychogeriatric nursing home patients significantly reduces the number of falls. This reduction is substantial and of high clinical relevance.

Background: The study aims to provide insight into the type of music being offered in Dutch nursing homes to patients with both dementia and verbal and vocal agitation. It also investigates the degree to which the music offered corresponds to the musical preferences of the nursing home residents., Method: Using random sampling, 20 nursing homes were selected to participate in this study. Within these homes, semi-structured interviews were conducted with nursing home physicians (n = 17) and other nursing home care providers (n = 20). Each interview focused on up to three psychogeriatric residents with verbal and vocal agitation. In total, 51 residents were discussed in the interviews., Results: For each resident, the frequency of music, the type of music being offered, and the degree of correspondence between the music being offered and the resident's preferences varied. In almost all cases, music was being offered in the communal living room during the mid-morning coffee and the afternoon tea, while music was only infrequently offered to residents during meals. However, this music was not tailored to the preferences of the residents. During patient-centered care activities in the early morning and before sleep, when offered, the music was generally tailored to the preferences of the resident(s)., Conclusion: Music is frequently played in nursing homes to patients with dementia who have verbal and vocal agitation. When offered to a group of residents, the music tends not to be tailored to the preferences of the residents. However, when offered individually, musical preferences are generally taken into account.

Background: Mental practice as an additional cognitive therapy is getting increased attention in stroke rehabilitation. A systematic review shows some evidence that several techniques in which movements are rehearsed mentally might be effective but not enough to be certain. This trial investigates whether mental practice can contribute to a quicker and/or better recovery of stroke in two Dutch nursing homes. The objective is to investigate the therapeutic potential of mental practice embedded in daily therapy to improve individually chosen daily activities of adult stroke patients compared to therapy as usual. In addition, we will investigate prognostic variables and feasibility (process evaluation)., Methods: A randomised, controlled, observer masked prospective trial will be conducted with adult stroke patients in the (sub)acute phase of stroke recovery. Over a six weeks intervention period the control group will receive multi professional therapy as usual. Patients in the experimental group will be instructed how to perform mental practice, and will receive care as usual in which mental practice is embedded in physical, occupation and speech therapy sessions. Outcome will be assessed at six weeks and six months. The primary outcome measure is the patient-perceived effect on performance of daily activities as assessed by an 11-point Likert Scale. Secondary outcomes are: Motricity Index, Nine Hole Peg Test, Barthel Index, Timed up and Go, 10 metres walking test, Rivermead Mobility Index. A sample size of the patients group and all therapists will be interviewed on their opinion of the experimental program to assess feasibility. All patients are asked to keep a log to determine unguided training intensity., Discussion: Advantages and disadvantages of several aspects of the chosen design are discussed., Trial Registration: ISRCTN27582267.

Objective: To describe the current use of the consultation function of nursing home physicians. Setting Descriptive inventory study., Methods: A questionnaire (with 16 questions regarding the consultation function of nursing home physicians) was sent to the head of the medical staff of all nursing homes in The Netherlands (n=323)., Results: The response to the questionnaire was 78%. The use of the consultation function appeared to be very low. Only 20% of respondents answered that their medical staff was involved in weekly or monthly consultations upon request of general practitioners. Respondents mentioned unfamiliarity with the expertise of nursing home physicians as the main reason for this low consultation frequency. A positive relationship was found between the consultation frequency and some organizational parameters., Conclusion: Nursing home physicians are not often consulted by general practitioners. Compared to 7 years ago even a decline in the consultation frequency has occurred. Paradoxically, the current trend in chronic care to offer care and treatment as long as possible in the home situation of patients, leads to a situation in which Dutch nursing homes offer more and more complementary nursing and medical support to community care for chronically ill and disabled patients, still living at home. This trend stresses also the importance of more collaboration between general practitioners and nursing home physicians. Further research concerning the added value of this collaboration is necessary

Objectives: The objectives of this study were to (i) survey the risk factors for NSAID gastropathy in outpatients (elderly patients in the community), compared to those living in old people's homes or nursing homes, (ii) study the prescription of medication prophylaxis during use of NSAIDs conform the current national guidelines and (iii) survey the influence on gastrointestinal symptoms and safety of pantoprazole 20 mg as prophylaxis for NSAID gastropathy., Methods: Patients over 65 years of age, using an NSAID without prophylaxis or newly starting NSAID treatment were included in the study. Pantoprazole 20 mg was prescribed as prophylaxis. Patients using an NSAID with prophylaxis being a proton pump inhibitor at the first visit were registered for epidemiological reasons. Demographic data, risk factors, gastrointestinal complaints, and adverse events were collected at t = 0, t = 2 weeks, t = 3 months and t = 6 months. Differences between groups were analysed with Chi-square tests and Mann-Whitney U tests; changes in time in GI symptoms were tested using Wilcoxon signed ranks tests and McNemar tests., Results: One hundred eighty one general practitioners (treating outpatients and patients in old people's homes)and five nursing home physicians participated in the study and a total of 615 patients were included (522 patients treated by general practitioners (GP) and 93 patients in nursing homes). Four hundred thirty two patients were using NSAIDs without prophylaxis or started using an NSAID at the first visit; 269 (62.1%) and 163 (37.9%) patients respectively. 65.3% of the outpatients (224 out of 343) did not receive indicated prophylaxis, versus 76.2% (16 out of 21) in old people's homes and 42.6% in nursing homes (29 out of 69) (P < 0.001). Patients in nursing homes had more risk factors for gastrointestinal complications (2.94 +/- 1.3 versus 1.77 +/- 0.9) than outpatients. More patients using an NSAID prior to the study complained of gastrointestinal symptoms compared to new users (P < 0.001). This seems to indicate that NSAIDs caused these symptoms. After 2 weeks of treatment with pantoprazole, there was no statistical difference between the two groups. Moreover, both groups showed improvement in complaints (P < 0.001). Only nine patients in the study population (3.1%) reported mild adverse events (e.g. nausea, headache) with an average of 1.1 adverse events per patient. Five patients (1% of the included population) died during the study period, but there was no relation to the NSAID or pantoprazole., Discussion and Conclusion: Patients in nursing homes had more risk factors for NSAID gastropathy than patients in old people's homes or outpatients (>65 years). Although in nursing homes co-prescription of prophylaxis during NSAID use is more common, in general the Dutch guidelines on adequate NSAID use are still not fully implemented at this moment. The results also showed that pantoprazole was effective in diminishing gastrointestinal complaints, as well as preventing symptomatic NSAID gastropathy. Moreover, pantoprazole showed to be a safe and well-tolerated drug in our treatment group.

Background: Demented nursing home patients are at high risk for falls. Falls and associated injuries can have a considerable influence on the autonomy and quality of life of patients. The prevention of falls among demented patients is therefore an important issue. In order to intervene in an efficient way in this group of patients, it is important to systematically evaluate the fall risk profile of each individual patient so that for each patient tailor-made preventive measures can be taken. Therefore, the objective of the present study is to develop a feasible and evidence based multidisciplinary fall risk evaluation tool to be used for tailoring preventive interventions to the needs of individual demented patients., Methods: To develop this multidisciplinary fall risk evaluation tool we have chosen to combine scientific evidence on the one hand and experts' opinions on the other hand. Firstly, relevant risk factors for falling in elderly persons were gathered from the literature. Secondly, a group of Dutch experts in the field of falls and fall prevention in the elderly were consulted to judge the suitability of these risk factors for use in a multidisciplinary fall risk evaluation tool for demented nursing home patients. Thirdly, in order to generate a compact list of the most relevant risk factors for falling in demented elderly, all risk factors had to fulfill a set of criteria indicating their relevance for this specific target population. Lastly the final list of risk factors resulting from the above mentioned procedure was presented to the expert group. The members were also asked to give their opinion about the practical use of the tool., Results: The multidisciplinary fall risk evaluation tool we developed includes the following items: previous falls, use of medication, locomotor functions, and (correct) choice and use of assistive and protective devices. The tool is developed for the multidisciplinary teams of the nursing homes., Conclusion: This evidence and practice based multidisciplinary fall risk evaluation tool targets the preventive interventions aimed to prevent falls and their negative consequences in demented nursing home patients.

Objective: To determine how many falls occur annually in Dutch nursing homes and how many fractures are the result of falls., Design: Written questionnaire study., Method: All 371 Dutch nursing homes received a questionnaire requesting information on the number of somatic and psychogeriatric beds and the number of falls and fractures as a result of falls in 2000 and 2001., Results: Of the 371 questionnaires, 202 (54%) were returned. These were distributed as follows over the three types of nursing homes: combined: 151 (75%), somatic: 15 (7%), psychogeriatric: 36 (18%). The average capacity of the participating nursing homes was 180 beds. There was an average of more than 300 reported falls per nursing home: 336 in 2000 (SD: 180; median 314) and 311 in 2001 (SD: 165, median 294). On average, there were almost 2 falls per bed per year. The number of falls per bed in the psychogeriatric group was higher than in the somatic group. There was an average of about 4 fractures per year per nursing home as a result of falls: 4.3 in 2000 (SD: 3.7; median 4.0) and 3.6 in 2oo1 (SD: 2.8; median 3.0). The average number of annual fractures due to a fall was about 23 per 1ooo beds. An average of 1.3% of the falls resulted in a fracture. There were no clear differences here between somatic and psychogeriatric patients., Conclusion: The reported number of falls per nursing-home bed averaged almost 2 per year, and an average of 1.3% of these falls resulted in a fracture.