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The purpose of this study is (1) to evaluate whether an educational program for preclinical students has an effect on the knowledge of professional behaviour for clerks and (2) to study how preclinical students compare with advanced clinical students concerning this knowledge. The authors used an observer-rated test consisting of vignettes describing a dilemma concerning professional behaviour. Students’ description of proposed behaviour was scored in one of three categories: unacceptable, acceptable or excellent. Preclinical students were compared with clinical students and the effect of an educational session on student scores on this test was assessed. The educational programme had a positive effect on student scores. However, the knowledge of professional behaviour did not generalize to situations that had not been the explicit topic of the session. A difference was found between preclinical and clinical students in two of the four vignettes: in one vignette clinical students had better scores, in another vignette they had worse scores. It is concluded that the educational programme had a positive effect on student knowledge of professional behaviour but there was no generalization. For more generic rules to sink in, probably many cases need to be discussed, with explicit attention paid to the rationales of these rules. Students who were advanced in their clerkships held different views on professional behaviour compared with preclinical students, possibly due to a socialization process. [ABSTRACT FROM AUTHOR]

Objectives To examine the effect of integrated emotion-oriented care on nursing home residents with dementia and nursing assistants. Design A multi-site randomized clinical trial with matched groups, and measurements at baseline and after seven months. Setting Sixteen psychogeriatric wards in fourteen nursing homes in the Netherlands. Participants One hundred and forty-six elderly residents with the diagnosis dementia of the Alzheimer (DAT) type, mixed DAT and vascular dementia, and dementia syndrome (NAO) and 99 nursing assistants. Interventions Integrated emotion-oriented care and usual care. Mesurements Demented elderly: Behaviour and mood related to adaptation to the illness and the institutionalization. Nursing assistants: General health as measured by feelings of stress, stress reactions, feeling of competence and illness. Results Positive effects in favour of the integrated emotion-oriented care were found in mild to moderately demented residents on two adaptive tasks: maintaining an emotional balance (less anxiety) and preserving a positive self-image (less dissatisfaction). In the trained group of nursing assistants fewer stress reactions were found only in those who perceived improvement in their emotion-oriented care skills after training. Conclusion Emotion-oriented care is more effective with regard to the emotional adaptation in nursing homes of persons with a mild to moderate dementia. For the severely demented elderly we did not find this surplus value. This outcome is of clinical importance for elderly persons with dementia who are cared for in nursing homes. With respect to the nursing assistants it is concluded that emotion-oriented care has a positive influence on stress reactions in some of them. Copyright © 2005 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Depression may be associated with cognitive decline in elderly people with impaired cognition.Aims: To investigate whether depressed elderly people with normal cognition are at increased risk of cognitive decline and Alzheimer's disease.Methods: Two independent samples of older people with normal cognition were selected from the community-based Amsterdam Study of the Elderly (AMSTEL) and the Longitudinal Aging Study Amsterdam (LASA). In AMSTEL, depression was assessed by means of the Geriatric Mental State Schedule. Clinical diagnoses of incident Alzheimer's disease were made using a two-step procedure. In LASA, depression was assessed with the Center for Epidemiologic Studies Depression Scale. Cognitive decline was defined as a drop of > or = 3 on the Mini-Mental State Examination at follow-up.Results: Both in the AMSTEL and the LASA sample, depression was associated with an increased risk of Alzheimer's disease and cognitive decline, respectively, but only in subjects with higher levels of education.Conclusions: In a subgroup of more highly educated elderly people, depression may be an early manifestation of Alzheimer's disease before cognitive symptoms become apparent. [ABSTRACT FROM AUTHOR]

Physician-assisted suicide can now be officially and legally carried out for psychiatric patients in the Netherlands who request it, provided that criteria are met. The authors describe two recent cases of psychiatric patients whose suicides were assisted by their psychiatrist. They critically examine the guidelines for physician-assisted suicide in psychiatry. The criteria address the decision of the patient to be assisted with suicide, which must be voluntary and well considered, and the patient's desire to die, which must endure over time. The patient's suffering must be unacceptable, and the disorder incurable. The authors conclude that important aspects of psychiatric practice are not addressed in the guidelines, which were originally developed for use in somatic medicine. The assessment of treatment prognosis in psychiatry is not accurate enough to allow a final decision about incurability. Boundaries of the psychiatric therapeutic relationship are violated in physician-assisted suicide. The therapist's inability to objectively assess the patient's wish to die is overlooked. Because the general public will continue to ask for clarity on the issue of euthanasia and physician-assisted suicide, the authors believe that an open discussion of both ethical and professional issues is the best option. [ABSTRACT FROM AUTHOR]

Doctors meet patients who present with non-genuine diseases. We present three patients who present with an illness with no organic cause: conversion syndrome, factitious disorder and simulation. We discuss the differential diagnosis, prevalence and diagnostics in the event of simulation. A proposal is made about how to respond in the event of simulation. The method is similar to the treatment of a factitious disorder: limitation of the potential benefits attached to the sick role; confrontation with medical facts; maintaining the doctor-patient relationship.

This case report offers a different perspective on a patient with a long-term non-psychotic psychiatric disorder that was difficult to specify. The patient, a man in his 50s, was unable to profit from outpatient treatment and became increasingly dependent on mental healthcare - which could not be understood based on his history and psychiatric symptoms alone. By separating symptoms from illness behaviour, the negative course of this patient's treatment is analysed. Focusing on ineffective chronic illness behaviour by the patient, and mutual ineffective treatment behaviour by the clinicians, it becomes clear that basic requirements of effective treatment were unmet. By making a proper diagnosis, clarifying expectations and offering a suitable therapy, ineffective illness behaviour was diminished and this 'difficult' case became much easier for both patient and clinicians. The illness behaviour framework offers a useful, systematic tool to analyse difficulties between patients and clinicians beyond psychiatric symptoms or explanations.

This article focuses on the assessment of competence of elderly persons both with and without cognitive impairment. In total 113 patients of a geriatric clinic were interviewed. Competence was assessed by using two clinical vignettes, representing respectively a hypothetical treatment situation with mild consequences (endoscopy) and one with severe consequences (operation for colon cancer). Competence was evaluated using the following standards: the ability to evidence a choice, the ability to understand a situation, the ability to reason about a choice, and the ability to appreciate a situation. In the vignette with mild consequences, elderly persons with cognitive impairment performed significantly worse on understanding, reasoning and appreciation than elderly persons without cognitive impairment. In the vignette with severe consequences, elderly persons with cognitive impairment performed significantly worse only on understanding as compared to elderly persons without cognitive impairment. No differences were found for reasoning and appreciation between the cognitively impaired and non-impaired elderly persons. We conclude that competence is less limited by cognitive impairment when assessed in a treatment situation with severe consequences. Therefore, the use of hypothetical vignettes should be carefully reconsidered.

Objective: To study the impact of depression on the wellbeing, disability and use of health services of older adults., Method: Prospective community-based study, using a large (n = 2,200) sample of the elderly (55-85) in the Netherlands. Using a 3-year follow-up, the effect of depressive symptoms (CES-D) on disability, wellbeing and service utilization was assessed, controlling for competing need-for-care (chronic physical illness, functional limitation and cognitive decline), enabling (partner status, size of the social network, social support and locus of control), and predisposing factors (age, sex and level of education)., Results: Depressive symptoms have considerable impact on the wellbeing and disability of older people and clear economic consequences caused by inappropriate service utilization. Compared with other need-for-care variables the impact of depression is weaker (service utilization), similar (disability) or stronger (wellbeing)., Conclusion: The steeply rising prevalence of competing health risks in later life does not influence the significance of depression.