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Background: To preserve quality and continuity of care, collaboration between primary-care and secondary-care physicians is becoming increasingly important. Therefore, learning intraprofessional collaboration (intraPC) requires explicit attention during postgraduate training. Hospital placements provide opportunities for intraPC learning, but these opportunities require interventions to support and enhance such learning. Design-Principles guide the design and development of educational activities when theory-driven Design-Principles are tailored into context-sensitive Design-Principles. The aim of this study was to develop and substantiate a set of theory-driven and context-sensitive Design-Principles for intraPC learning during hospital placements. Methods: Based on our earlier research, we formulated nine theory-driven Design-Principles. To enrich, refine and consolidate these principles, three focus group sessions with stakeholders were conducted using a Modified Nominal Group Technique. Next, two work conferences were conducted to test the feasibility and applicability of the Design-Principles for developing intraPC educational activities and to sharpen the principles into a final set of Design-Principles. Results: The theoretical Design-Principles were discussed and modified iteratively. Two new Design-Principles were added during focus group 1, and one more Design-Principle was added during focus group 2. The Design-Principles were categorised into three clusters: (i) Culture: building collaborative relations in a psychologically safe context where patterns or feelings of power dynamics between primary and secondary care physicians can be discussed; (ii) Connecting Contexts: making residents and supervisors mutually understand each other's work contexts and activities; and (iii) Making the Implicit Explicit: having supervising teams act as role models demonstrating intraPC and continuously pursuing improvement in intraPC to make intraPC explicit. Participants were unanimous in their view that the Design-Principles in the Culture cluster were prerequisites to facilitate intraPC learning. Conclusion: This study led to the development of 12 theory-driven and context-sensitive Design-Principles that may guide the design of educational activities to support intraPC learning during hospital placements.

Background: Malnutrition and dehydration are widespread in older people, and obesity is an increasing problem. In clinical practice, it is often unclear which strategies are suitable and effective in counteracting these key health threats. Aim: To provide evidence-based recommendations for clinical nutrition and hydration in older persons in order to prevent and/or treat malnutrition and dehydration. Further, to address whether weight-reducing interventions are appropriate for overweight or obese older persons. Methods: This guideline was developed according to the standard operating procedure for ESPEN guidelines and consensus papers. A systematic literature search for systematic reviews and primary studies was performed based on 33 clinical questions in PICO format. Existing evidence was graded according to the SIGN grading system. Recommendations were developed and agreed in a multistage consensus process. Results: We provide eighty-two evidence-based recommendations for nutritional care in older persons, covering four main topics: Basic questions and general principles, recommendations for older persons with malnutrition or at risk of malnutrition, recommendations for older patients with specific diseases, and recommendations to prevent, identify and treat dehydration. Overall, we recommend that all older persons shall routinely be screened for malnutrition in order to identify an existing risk early. Oral nutrition can be supported by nursing interventions, education, nutritional counselling, food modification and oral nutritional supplements. Enteral nutrition should be initiated if oral, and parenteral if enteral nutrition is insufficient or impossible and the general prognosis is altogether favorable. Dietary restrictions should generally be avoided, and weight-reducing diets shall only be considered in obese older persons with weight related health problems and combined with physical exercise. All older persons should be considered to be at risk of low-intake dehydration and encouraged to consume adequate amounts of drinks. Generally, interventions shall be individualized, comprehensive and part of a multimodal and multidisciplinary team approach. Conclusion: A range of effective interventions is available to support adequate nutrition and hydration in older persons in order to maintain or improve nutritional status and improve clinical course and quality of life. These interventions should be implemented in clinical practice and routinely used.

Contains fulltext : 229569.pdf (Publisher’s version ) (Open Access) CONTEXT: Intraprofessional collaboration (intraPC) between primary care (PC) doctors and medical specialists (MSs) is becoming increasingly important. Patient safety issues are often related to intraPC. In order to equip doctors well for their task of providing good quality and continuity of care, intraPC needs explicit attention, starting in postgraduate training. Worldwide, PC residents undertake a hospital placement during their postgraduate training, where they work in proximity with MS residents. This placement offers the opportunity to learn intraPC. It is yet unknown whether and how residents learn intraPC and what barriers to and opportunities for exist in learning intraPC during hospital placements. METHODS: We performed an ethnographic non-participatory observational study in three emergency departments and three geriatric departments of five hospitals in the Netherlands. This was followed by 42 in-depth interviews with the observed residents and supervisors. The observations were used to feed the questions for the in-depth interviews. We analysed the interviews iteratively following the data collection using template analysis. RESULTS: Hospital wards are rich in opportunities for learning intraPC. These opportunities, however, are seldom exploited for various reasons: intraPC receives limited attention when formulating placement goals, so purposeful learning of intraPC hardly takes place; residents lack awareness of the learning of intraPC; MS residents are not accustomed to searching for expertise from PC residents; PC residents adapt to the MS role and they contribute very little of their PC knowledge, and power dynamics in the hospital department negatively influence the learning of intraPC. Therefore, improvements in mindset, professional identity and power dynamics are crucial to facilitate and promote intraPC. CONCLUSIONS: Intraprofessional collaboration is not learned spontaneously during hospital placements. To benefit from the abundant opportunities to learn intraPC, adjustments to the set-up of these placements are necessary. Learning intraPC is promoted when there is a collaborative culture, hierarchy is limited, and there is dedicated time for intraPC and support from the supervisor.

Contains fulltext : 249090.pdf (Publisher’s version ) (Open Access) BACKGROUND: During postgraduate training, considerable efforts for intraprofessional education are in place to prepare primary care residents (PC residents) and medical specialty residents (MS residents) for intraprofessional collaboration (intraPC). Power dynamics are inherently present in such hierarchical medical contexts. This affects intraPC (learning). Yet little attention has been paid to factors that impact power dynamics. This study aims to explore power dynamics and their impact on intraPC learning between PC residents and MS residents during hospital placements. METHODS: This study expands on previously published ethnographic research investigating opportunities and barriers for intraPC learning among residents in five Dutch hospitals. We analysed transcripts of observations and in-depth interviews using template analysis. A critical theory paradigm was employed. Discourse analysis additionally informed the data. RESULTS: We defined five interrelated themes that describe characteristics of power dynamics in intraPC learning during hospital placements: beliefs; power distribution; interaction style; subjection; and fearless learning. Power dynamics operate both within and between the themes: power distribution between PC residents, MS residents and MS supervisors seemed to be an attribution affected by underlying beliefs about professional norms or about other professions; beliefs influenced the way PC residents, MS residents and MS supervisors interacted; power distribution based on inequity could lead to subjection of PC residents; power distribution based on equity could lead to fearless learning; and open interactions enabled fearless intraPC learning. CONCLUSIONS: Power dynamics have an impact on intraPC learning among residents in hospitals. Constructive power dynamics occur when power distribution is based on equity, combined with sincere open interactions, actively inviting each other into discussions and enlisting the support of MS supervisors to foster fearless learning. This can be achieved by creating awareness of implicit beliefs and making them explicit, recognising interaction that encourages intraPC learning and creating policies that support fearless intraPC learning.

BACKGROUND Geriatricians are often confronted with unexpected health outcomes in older adults with complex multimorbidity. Aging researchers have recently called for a focus on physical resilience as a new approach to explaining such outcomes. Physical resilience, defined as the ability to resist functional decline or recover health following a stressor, is an emerging construct. METHODS Based on an outline of the state-of-the-art in research on the measurement of physical resilience, this article describes what tests to predict resilience can already be used in clinical practice and which innovations are to be expected soon. RESULTS An older adult's recovery potential is currently predicted by static tests of physiological reserves. Although geriatric medicine typically adopts a multidisciplinary view of the patient and implicitly performs resilience management to a certain extent, clinical management of older adults can benefit from explicitly applying the dynamical concept of resilience. Two crucial leads for advancing our capacity to measure and manage the resilience of individual patients are advocated: first, performing multiple repeated measurements around a stressor can provide insight about the patient's dynamic responses to stressors; and, second, linking psychological and physiological subsystems, as proposed by network studies on resilience, can provide insight into dynamic interactions involved in a resilient response. CONCLUSION A big challenge still lies ahead in translating the dynamical concept of resilience into clinical tools and guidelines. As a first step in bridging this gap, this article outlines what opportunities clinicians and researchers can already exploit to improve prediction, understanding, and management of resilience of older adults. J Am Geriatr Soc 67:2650-2657, 2019.

To investigate qualitatively how residents cope with clinical uncertainty while caring for their complex geriatric patients. Residents experience clinical uncertainty and judge it positive as well as negative. Despite the impact on their feelings, behavior and well-being, they do not discuss it with others. Clinical uncertainty is an inherent part of caring for complex geriatric patients and influences the well-being of residents, but training in tolerance of clinical uncertainty is lacking. With the growing complexity in health care, clinical uncertainty increases, even more so in geriatrics. Intolerance of clinical uncertainty can result in stress, burnout and additional costs. This makes tolerance of clinical uncertainty a highly relevant skill to learn. This study investigated how residents cope with clinical uncertainty and explored options to improve their tolerance of it. We interviewed nine residents from the geriatric department of a university medical center and analyzed the interviews conform template analysis using the ‘integrative model of uncertainty tolerance’. All residents experienced clinical uncertainty regularly and emphasized it was a relevant topic. Residents described clinical uncertainty as both negative and positive, explaining it was difficult to deal with and could lead to stress, but it also kept them focused, challenged them and stimulated learning. While most of the reported topics fitted in the theoretical model, the model did not reflect the dynamics of clinical uncertainty and lacked its consequences outside the workplace. Residents mainly responded to clinical uncertainty by asking supervisors and peers to double-check their decisions concerning a patient. Residents indicated that they barely discussed their own emotions, cognitions or learning processes with peers or their supervisors. They would welcome the incorporation of clinical uncertainty as standard theme in patient supervision and educational meetings. Clinical uncertainty is not a problem of an insecure, failing resident, but an inherent part of caring for complex geriatric patients. Residents deserve to be trained in tolerance of clinical uncertainty to improve their well-being and care for geriatric patients.

International audience; The population of patients with moderate and severe CKD is growing. Frail and older patients comprise an increasing proportion. Many studies still exclude this group, so the evidence base is limited. In 2013 the advisory board of ERBP initiated, in collaboration with European Union of Geriatric Medicine Societies (EUGMS), the development of a guideline on the management of older patients with CKD stage 3b or higher (eGFR \textgreater 45 mL/min/1.73 m(2)). The full guideline has recently been published and is freely available online and on the website of ERBP (www.european-renal-best-practice.org). This paper summarises main recommendations of the guideline and their underlying rationales.

The population of patients with moderate and severe CKD is growing. Frail and older patients comprise an increasing proportion. Many studies still exclude this group, so the evidence base is limited. In 2013 the advisory board of ERBP initiated, in collaboration with European Union of Geriatric Medicine Societies (EUGMS), the development of a guideline on the management of older patients with CKD stage 3b or higher (eGFR >45 mL/min/1.73 m2). The full guideline has recently been published and is freely available online and on the website of ERBP (www.european-renal-best-practice.org). This paper summarises main recommendations of the guideline and their underlying rationales.

Summary Background Malnutrition and dehydration are widespread in older people, and obesity is an increasing problem. In clinical practice, it is often unclear which strategies are suitable and effective in counteracting these key health threats. Aim To provide evidence-based recommendations for clinical nutrition and hydration in older persons in order to prevent and/or treat malnutrition and dehydration. Further, to address whether weight-reducing interventions are appropriate for overweight or obese older persons. Methods This guideline was developed according to the standard operating procedure for ESPEN guidelines and consensus papers. A systematic literature search for systematic reviews and primary studies was performed based on 33 clinical questions in PICO format. Existing evidence was graded according to the SIGN grading system. Recommendations were developed and agreed in a multistage consensus process. Results We provide eighty-two evidence-based recommendations for nutritional care in older persons, covering four main topics: Basic questions and general principles, recommendations for older persons with malnutrition or at risk of malnutrition, recommendations for older patients with specific diseases, and recommendations to prevent, identify and treat dehydration. Overall, we recommend that all older persons shall routinely be screened for malnutrition in order to identify an existing risk early. Oral nutrition can be supported by nursing interventions, education, nutritional counseling, food modification and oral nutritional supplements. Enteral nutrition should be initiated if oral, and parenteral if enteral nutrition is insufficient or impossible and the general prognosis is altogether favorable. Dietary restrictions should generally be avoided, and weight-reducing diets shall only be considered in obese older persons with weight-related health problems and combined with physical exercise. All older persons should be considered to be at risk of low-intake dehydration and encouraged to consume adequate amounts of drinks. Generally, interventions shall be individualized, comprehensive and part of a multimodal and multidisciplinary team approach. Conclusion A range of effective interventions is available to support adequate nutrition and hydration in older persons in order to maintain or improve nutritional status and improve clinical course and quality of life. These interventions should be implemented in clinical practice and routinely used.

Multidisciplinary meetings (MDMs) have become an established part of many medical disciplines. Much research has been done to investigate the conditions under which they work best. This research, however, has been mostly retrospective and has had little consideration for the actual workings of MDMs. The aim of this study was to determine how Multidisciplinary Teams (MDTs) come to a shared decision and thus how they organize MDMs moment by moment. For this purpose we recorded twenty MDMs at the Department of Emergency Medicine (ED) of the Radboud University Medical Center in The Netherlands between November 2017 and June 2018. These meetings, contrary to those discussed in the literature, were scheduled ad-hoc as patients were seen at the ED and were conducted by small MDTs of between three and six participants, always involving a surgeon, a geriatrician, and an emergency physician. Using Conversation Analysis we found that despite the ad hoc nature of these meetings, teams collaboratively developed a structure that was grounded in everyday medical practice and reached a decision in on average slightly over 10 min. First they do a case presentation in which they share the patient's medical history and results of the physical examination and any medical tests. They subsequently agree on a differential diagnosis, and then develop a work plan. Finally, the decision is often formulated to invite confirmation and make it an interactionally shared decision. The benefit of having an MDM was evidenced by discussion of patients' frailty in particular: it was sometimes omitted during the case presentation, but then consistently requested by the geriatrician. And as we show, it was occasionally invoked as a definitive argument for deciding between surgical or conservative treatment. Our analysis suggests that MDMs can have added value in other disciplines where it is feasible to schedule meetings ad hoc.

Introduction: There is little knowledge of the long-term course of Alzheimer disease (AD) in light of current pharmacological and nonpharmacological interventions provided in a "real-life" setting. Methods: The Frisian Alzheimer's Disease Cohort study is a "real-life" study of the course of AD in patients (n=576) treated with pharmacological (ie, cholinesterase inhibitors) and nonpharmacological (ie, case management, respite care) interventions. Disease course was described by changes in cognition (Mini Mental State Examination, clock-drawing test) and number of types of professional care applying a repeated-measures analysis using a marginal model (population-based average model). In addition, behavioral and psychological symptoms, and proportions of nursing home admissions and deaths were investigated. Results: During 3.5 years, the average Mini Mental State Examination decreased from 22.24 to 18.91, the clock-drawing test score increased from 3.38 to 4.05, the number of types of professional care increased from 0.85 to 2.64, and the patients with behavioral and psychological symptoms increased from 29.0% to 70.2%. The proportion of patients admitted to a nursing home was 40.8% and 41.0% died. Conclusions: Cognition and behaviour of AD patients deteriorated accompanied with an increase in care-dependency during 3.5 years. Nevertheless, compared with the precholinesterase inhibitor era, current pharmacological and nonpharmacological interventions appear to slow cognitive decline, which emphasizes that they seem to have a favorable effect.

In frail older patients, an atypical disease presentation such as a sudden mobility problem or hyperactivity in delirium is often the only signal that a new disease episode occurred. Classical signals of disease may be lacking completely. In fact, atypical symptoms are the most typical characteristics of geriatric patients and urge for a comprehensive geriatric assessment (CGA) to find the causes. Frailty causes close interactions between organs with decreased physiological reserve. The atypical symptoms originate from the individual patient’s most frail organ, which is closely linked to the ill or stressed organ at which the disease episode started. Atypical symptoms mostly have a multifactorial causality with a recent precipitating factor, also called acute geriatric syndromes or geriatric giants. Similarly, more chronic atypical presentations may result in chronic geriatric syndromes, such as malnutrition or cognitive decline. The chapter closes with general guidelines on how to apply evidence-based medicine (EBM) and shared decision-making (SDM) to frail older adults with their complex multicausality and varying treatment wishes.

Worldwide approximately two billion people have a diet insufficient in micronutrients. Even in the developed world, an increasing number of people consume nutrient-poor food on a regular basis. Recent surveys in Western countries consistently indicate inadequate intake of nutrients such as vitamins and minerals, compared to recommendations. The International Osteoporosis Foundation's (IOF) latest figures show that globally about 88% of the population does not have an optimal vitamin D status. The Lancet's "Global Burden of Disease Study 2010" demonstrates a continued growth in life expectancy for populations around the world; however, the last decade of life is often disabled by the burden of partly preventable health issues. Compelling evidence suggests that improving nutrition protects health, prevents disability, boosts economic productivity and saves lives. Investments to improve nutrition make a positive contribution to long-term national and global health, economic productivity and stability, and societal resilience.

With the aging of the population, the interest in clinical trials concerning frail elderly patients has increased. Evidence-based practice for the elderly patient is difficult because elderly patients, especially the frail, are often excluded from clinical trials. To facilitate the participation of frail elderly patients in clinical trials, investigators should be more aware of possible barriers when setting up research. While conducting a trial entitled 'A randomized controlled trial of geriatric liaison intervention in frail surgical oncology patients' (LIFE) the main problem was low inclusion rates. This was due to: 1) limited physical and cognitive. reserve of frail elderly patients making participation and extra visits to the hospital a burden for patients; 2) difficulty with understanding written information and information given by telephone; and 3) insufficient awareness of the study by health care professionals. To increase inclusion rates, follow-up measurements were taken at a home visit. To overcome barriers to understanding written information and information given over the phone, patients were informed face to face and questionnaires were filled in an interview format. To increase awareness, posters, pencil and sweets with the logo of the study were distributed and the study protocol was repeatedly explained to new staff. Moreover, it was checked if possible eligible patients coming to the hospital were indeed screened for participation. The mentioned measures, increased inclusion rates but also caused an increased time investment and consequently extra financial resources for staff costs. (C) 2012 Elsevier Ltd. All rights reserved.

Item does not contain fulltext OBJECTIVE: scientific evidence regarding the optimal management of malnutrition in geriatric patients is scarce. Our aim was to develop a consensus statement for geriatric hospital practice concerning six elements: (i) definition of malnutrition, (ii) screening and assessment, (iii) treatment and monitoring, (iv) roles and responsibilities of involved health care professionals, (v) communication and coordination of care between hospital and community health care professionals, (vi) quality indicators for malnutrition management. DESIGN: a modified Delphi study. METHODS: eleven geriatricians with special interest in malnutrition participated. In four rounds the experts rated the relevance of 204 statements, which were based on a literature review, on a five-point Likert scale. From the responses, means and 95% CIs were calculated. Consensus was defined as a lower 95% confidence limit >/=4.0. RESULTS: the panel reached consensus that malnutrition should be considered a geriatric syndrome. The nutritional status should be assessed using the Mini Nutritional Assessment combined with comprehensive geriatric assessment. Nutritional interventions should be combined with interventions targeting underlying factors. Specific goals for nutritional therapy and ways to achieve them were agreed upon. According to the experts, malnutrition is best managed by a multidisciplinary team for whom roles and responsibilities were specified. At discharge written information about the nutritional problem, treatment plan and goals should be provided to the patient, caregiver and community health care professionals. CONCLUSION: this study shows that a qualitative study based on a modified Delphi technique can result in national consensus on essential ingredients for a practical malnutrition guideline for geriatric patients. 01 mei 2012

Background: Delirium is one of the most serious complications in hospitalized elderly, with incidences ranging from 3-56%. The objective of this meta-analysis was two-fold, first to investigate if interventions to prevent delirium are effective and second to explore which factors increase the effectiveness of these interventions. Methods: An electronic search was carried out on articles published between January 1979 and July 2009. Abstracts were reviewed, data were extracted and methodologic quality was assessed by two independent reviewers. Effect sizes of the interventions were expressed as ORs (odds ratios) and 95% CIs (confidence intervals). A random effect model was used to provide pooled ORs. To explore which factors increase the effectiveness of the interventions, ORs were stratified for several factors. Results: Sixteen relevant studies were found. Overall the included studies showed a positive result of any intervention to prevent delirium (pooled OR: 0.64; 95% CI: 0.46-0.88). The largest effect was seen in studies on populations with an incidence of delirium above 30% in the control group (pooled OR: 0.34; 95% CI: 0.16-0.71 versus 0.76; 95% CI: 0.60-0.97). Conclusions: Interventions to prevent delirium are effective. Interventions seem to be more effective when the incidence of delirium in the population under study is above 30%. To maximize the options for a cost-effective strategy of delirium prevention it might be useful to offer an intervention to a selected population. Copyright (c) 2010 John Wiley & Sons, Ltd.

Introduction: Weight loss has been described in 20% to 45% of patients with Alzheimer's disease (AD) and has been associated with adverse outcomes. Various mechanisms for weight loss in AD patients have been proposed, though none has been proven. This study aimed to elucidate a mechanism of weight loss in AD patients by examining the hypothesis that weight loss is associated with medial temporal lobe atrophy (MTA).Methods: Patients from the Frisian Alzheimer's disease cohort study (a retrospective, longitudinal study of 576 community-dwelling AD patients) were included when a brain MRI was performed on which MTA could be assessed. To investigate the hypothesis that weight loss is associated with MTA, we investigated whether the trajectory of body weight change depends on the severity of MTA at the time of diagnosis (that is baseline). We hypothesized that patients with more severe MTA at baseline would have a lower body weight at baseline and a faster decrease in body weight during the course of the disease. The generalized linear mixed model (GLMM) was used to determine the relationship of weight change trajectory with MTA severity.Results: In total, 214 patients (median age 79 years, median MMSE 23, mean weight 73.9 kg) were included. Patients with moderate, severe or very severe MTA at baseline weighed 3.2 to 6.8 kg more than patients with no or mild MTA. During the 3.5 years, patients gained on average 1.7 kg in body weight, irrespective of the severity of their MTA at baseline.Conclusions: We found no evidence that MTA is associated with weight loss in AD patients. Moreover, contrary to what was expected, AD patients did not lose but gained weight during follow-up.

BACKGROUND:The aim of this study was to evaluate the long term effects after discharge of a hospital-based geriatric liaison intervention to prevent postoperative delirium in frail elderly cancer patients treated with an elective surgical procedure for a solid tumour. In addition, the effect of a postoperative delirium on long term outcomes was examined. METHODS:A three month follow-up was performed in participants of the Liaison Intervention in Frail Elderly study, a multicentre, prospective, randomized, controlled trial. Patients were randomized to standard treatment or a geriatric liaison intervention. The intervention consisted of a preoperative geriatric consultation, an individual treatment plan targeted at risk factors for delirium and daily visits by a geriatric nurse during the hospital stay. The long term outcomes included: mortality, rehospitalisation, Activities of Daily Living (ADL) functioning, return to the independent pre-operative living situation, use of supportive care, cognitive functioning and health related quality of life. RESULTS:Data of 260 patients (intervention n = 127, Control n = 133) were analysed. There were no differences between the intervention group and usual-care group for any of the outcomes three months after discharge. The presence of postoperative delirium was associated with: an increased risk of decline in ADL functioning (OR: 2.65, 95% CI: 1.02-6.88), an increased use of supportive assistance (OR: 2.45, 95% CI: 1.02-5.87) and a decreased chance to return to the independent preoperative living situation (OR: 0.18, 95% CI: 0.07-0.49). CONCLUSIONS:A hospital-based geriatric liaison intervention for the prevention of postoperative delirium in frail elderly cancer patients undergoing elective surgery for a solid tumour did not improve outcomes 3 months after discharge from hospital. The negative effect of a postoperative delirium on late outcome was confirmed. TRIAL REGISTRATION:Nederlands Trial Register, Trial ID NTR 823.

Background:Weight loss and undernutrition are common in patients with Alzheimer's disease (AD) and associated with negative health outcomes. In the current guidelines on diagnosis and treatment of AD, no recommendations for treatment of (risk of) undernutrition in community-dwelling AD patients are given.Methods:We conducted a systematic review on the effect of nutritional interventions in community-dwelling AD patients with (risk of) undernutrition, according to the methods outlined by the Cochrane Collaboration. Three electronic databases and three trial registers were searched from inception till April 2013.Results:Literature search in the electronic databases yielded 546 records of which one was relevant for this review. This study, with a high risk of bias, demonstrated that oral nutritional supplements improved nutritional outcomes without effect on clinical and biochemical outcomes. The search in the trial registers yielded 369 records of which two were relevant. One trial was terminated because of failing inclusion, the other is ongoing.Conclusions:This systematic review on the effect of nutritional interventions in community-dwelling AD patients with (risk of) undernutrition, reveals a serious lack of evidence. Therefore, it is not possible to state what the best approach is.

Contains fulltext : 137789.pdf (Publisher’s version ) (Open Access) Background: Studies on the systemic availability of nutrients and nutritional status in Alzheimer's disease (AD) are widely available, but the majority included patients in a moderate stage of AD. Objective: This study compares the nutritional status between mild AD outpatients and healthy controls. Methods: A subgroup of Dutch drug-naive patients with mild AD (Mini-Mental State Examination (MMSE) >/=20) from the Souvenir II randomized controlled study (NTR1975) and a group of Dutch healthy controls were included. Nutritional status was assessed by measuring levels of several nutrients, conducting the Mini Nutritional Assessment (MNA(R)) questionnaire and through anthropometric measures. Results: In total, data of 93 healthy cognitively intact controls (MMSE 29.0 [23.0-30.0]) and 79 very mild AD patients (MMSE = 25.0 [20.0-30.0]) were included. Plasma selenium (p < 0.001) and uridine (p = 0.046) levels were significantly lower in AD patients, with a similar trend for plasma vitamin D (p = 0.094) levels. In addition, the fatty acid profile in erythrocyte membranes was different between groups for several fatty acids. Mean MNA screening score was significantly lower in AD patients (p = 0.008), but not indicative of malnutrition risk. No significant differences were observed for other micronutrient or anthropometric parameters. Conclusion: In non-malnourished patients with very mild AD, lower levels of some micronutrients, a different fatty acid profile in erythrocyte membranes and a slightly but significantly lower MNA screening score were observed. This suggests that subtle differences in nutrient status are present already in a very early stage of AD and in the absence of protein/energy malnutrition.

Background Delirium is a serious and common postoperative complication, especially in frail elderly patients. The aim of this study was to evaluate the effect of a geriatric liaison intervention in comparison with standard care on the incidence of postoperative delirium in frail elderly cancer patients treated with an elective surgical procedure for a solid tumour. Methods Patients over 65 years of age who were undergoing elective surgery for a solid tumour were recruited to a multicentre, prospective, randomized, controlled trial. The patients were randomized to standard treatment versus a geriatric liaison intervention. The intervention consisted of a preoperative geriatric consultation, an individual treatment plan targeted at risk factors for delirium, daily visits by a geriatric nurse during the hospital stay and advice on managing any problems encountered. The primary outcome was the incidence of postoperative delirium. The secondary outcome measures were the severity of delirium, length of hospital stay, complications, mortality, care dependency, quality of life, return to an independent preoperative living situation and additional care at home. Results In total, the data of 260 patients were analysed. Delirium occurred in 31 patients (11.9%), and there was no significant difference between the incidence of delirium in the intervention group and the usual-care group (9.4% vs. 14.3%, OR: 0.63, 95% CI: 0.29–1.35). Conclusions Within this study, a geriatric liaison intervention based on frailty for the prevention of postoperative delirium in frail elderly cancer patients undergoing elective surgery for a solid tumour has not proven to be effective. Trial Registration Nederlands Trial Register Trial ID NTR 823