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BACKGROUND AND AIMS: The increase in the proportion of elderly people and a consequent increase in the demand for care have caused healthcare systems to become overloaded. This paper describes the use of Home Care Quality Indicators (HCQIs), derived from the Minimum Data Set for Home Care, for monitoring quality of care. Research questions were, 'Do HCQI scores vary between home care organizations in different countries?' and 'Are one or more country-specific sites consistently scoring better on most or all HCQIs'? METHODS: a cross-sectional observational study of 65+ randomly selected clients of home care organizations in urban areas in 11 European countries who had been receiving home care for at least two weeks. Data were collected with the MDS-HC. The scoring of 16 prevalent quality indicators for home care, adjusted for population differences, was calculated with baseline data. RESULTS: Population size at baseline was 4,007 clients. Among home care clients in Europe, 'rehabilitation potential in Activities of Daily Living and no therapies' (average 75.9%) and 'inadequate pain control' were the most common quality problems. The prevalence between populations studied in various countries varied substantially. No country-specific site consistently scored worst or best. CONCLUSIONS: HCQIs derived from the MDS-HC detect variance in quality scores between home care in the 11 partner countries. The highest prevalence of unwanted outcomes were most often found in the Czech Republic, Italy and Germany. Although further research is necessary, we believe that HCQIs may be of great value for quality improvement in home care. [ABSTRACT FROM AUTHOR]

PURPOSE: to compare cross-nationally the sources and rates of admission and discharge in nursing homes. METHODS: data on admission were used from the Minimum Data Set of the Resident Assessment Instrument as collected in a multi-nation database at the University of Michigan. Additional data containing longitudinal episodes were used from databases in the Netherlands, Switzerland and the USA. RESULTS: the sources and rates of admission and discharge in nursing homes vary widely between countries. In Japan 47.5% of the sample was admitted from another long-term care setting, in Italy and the USA 36% and 42% respectively were admitted directly from hospital, while in Denmark and Iceland more than 60% came from home. The longitudinal data show that in the Netherlands, residents' return to home was much more likely than in Geneva or the USA (27% vs 5% vs 10%) and that in the USA a relatively large number of nursing home residents (>45%) was discharged (intermittently) to a hospital within 180 days after first admission as compared to the Netherlands (10%). CONCLUSIONS: there are large differences between countries in admission and discharge to and from nursing homes. Various policies, payment schemes, care patterns and routine referrals influence this and can be studied with cross-national data now available. [ABSTRACT FROM AUTHOR]

Background: A multi-domain suite of instruments has been developed by the interRAI research collaborative to support assessment and care planning in mental health, aged care and disability services. Each assessment instrument comprises items common to other instruments and specialized items exclusive to that instrument. This study examined the reliability of the items from five instruments supporting home care, long term care, mental health, palliative care and post-acute care.Methods: Paired assessments on 783 individuals across 12 nations were completed within 72 hours of each other by trained assessors who were blinded to the others' assessment. Reliability was tested using weighted kappa coefficients.Results: The overall kappa mean value for 161 items which are common to 2 or more instruments was 0.75. The kappa mean value for specialized items varied among instruments from 0.63 to 0.73. Over 60% of items scored greater than 0.70.Conclusion: The vast majority of items exceeded standard cut-offs for acceptable reliability, with only modest variation among instruments. The overall performance of these instruments showed that the interRAI suite has substantial reliability according to conventional cut-offs for interpreting the kappa statistic. The results indicate that interRAI items retain reliability when used across care settings, paving the way for cross domain application of the instruments as part of an integrated health information system. [ABSTRACT FROM AUTHOR]

Background: Primary care-based comprehensive care programs have the potential to improve outcomes in frail older adults. We evaluated the impact of the Geriatric Care Model (GCM) on the quality of life of community-dwelling frail older adults., Methods: A 24-month stepped wedge cluster randomized controlled trial was conducted between May 2010 and March 2013 in 35 primary care practices in the Netherlands, and included 1147 frail older adults. The intervention consisted of a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Reassessment occurred every six months. Nurses worked together with primary care physicians and were supervised and trained by geriatric expert teams. Complex patients were reviewed in multidisciplinary consultations. The primary outcome was quality of life (SF-12). Secondary outcomes were health-related quality of life, functional limitations, self-rated health, psychological wellbeing, social functioning and hospitalizations., Results: Intention-to-treat analyses based on multilevel modeling showed no significant differences between the intervention group and usual care regarding SF-12 and most secondary outcomes. Only for IADL limitations we found a small intervention effect in patients who received the intervention for 18months (B=-0.25, 95%CI=-0.43 to -0.06, p=0.007), but this effect was not statistically significant after correction for multiple comparisons., Conclusion: The GCM did not show beneficial effects on quality of life in frail older adults in primary care, compared to usual care. This study strengthens the idea that comprehensive care programs add very little to usual primary care for this population., Trial Registration: The Netherlands National Trial Register NTR2160., (Copyright © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Objective: Little is known about factors that may prevent or delay adverse health outcomes in frail older adults. Previous studies have demonstrated beneficial effects of psychosocial resources on health outcomes in older adults. The aim of this study was to investigate whether psychosocial resources modify the effects of frailty on functional decline and mortality., Methods: The study sample consisted of 1665 men and women aged 58 and over from two waves of the Longitudinal Aging Study Amsterdam (LASA), a population based study. Frailty and psychosocial resources were assessed at T1 (2005/2006). Frailty was assessed using the criteria of Fried's phenotype. Psychosocial resources included sense of mastery, self-efficacy, instrumental support and emotional support. Functional decline and mortality were assessed at T2 (2008/2009)., Results: Results of logistic regression analyses demonstrated that frail older adults had higher odds of both functional decline (OR=2.63, 95% CI=1.61-4.27) and 3-year mortality (OR=3.17, 95% CI=1.95-5.15). After adjustment for covariates, higher levels of mastery and self-efficacy were associated with decreased odds of functional decline, but not mortality. No statistically significant interaction effects between frailty and psychosocial resources were found for either functional decline or mortality., Conclusion: This study found no evidence that psychosocial resources buffer against functional decline and mortality in frail older adults., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to examine the longitudinal association between educational level and frailty prevalence in older adults and to investigate the role of material, biomedical, behavioral, social, and mental factors in explaining this association., Methods: Data over a period of 13 years were used from the Longitudinal Aging Study Amsterdam. The study sample consisted of older adults aged 65 years and above at baseline (n = 1205). Frailty was assessed using Fried's frailty criteria. A relative index of inequality was calculated for the level of education. Longitudinal logistic regression analyses based on multilevel modeling were performed., Results: Older adults with a low educational level had higher odds of being frail compared with those with a high educational level (relative index of inequality odds ratio, 2.94; 95% confidence interval, 1.84-4.71). These differences persisted during 13 years of follow-up. Adjustment for all explanatory factors reduced the effect of educational level on frailty by 76%. Income, self-efficacy, cognitive impairment, obesity, and number of chronic diseases had the largest individual contribution in reducing the effect. Social factors had no substantial contribution., Conclusions: Our findings highlight the need for a multidimensional approach in developing interventions aimed at reducing frailty, especially in lower educated groups., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Antipsychotic drugs (APD) are widely prescribed for people with dementia residing in long term care facilities (LTCFs). Concern has been expressed that such prescribing is largely inappropriate. The objective of this study is to examine if differences in facility-level prevalence of APD use in a sample of LTCFs for patients with dementia can be explained by patient and facility-related characteristics., Methods: A point prevalence study was conducted using data from the VU University Resident Assessment Instrument (VURAI) database from nursing homes and residential care facilities in the Netherlands. Patients were selected who had a diagnosis of dementia. LTCF and patient characteristics were extracted from the VURAI; facility-level resident satisfaction surveys were provided by the National Institute for Public Health., Results: In total, 20 LTCFs providing care for 1,090 patients with dementia were investigated. Overall, 31% of patients used an APD. In facilities with a high prevalence of APD use behavioral symptoms were present in 62% of their patients. In facilities with medium APD use behavioral problems remained frequent (57%), and in facilities with low prevalence of APD use 54% of the patients had behavioral symptoms. Facilities with a high prevalence of APD use were often large, situated in urban communities, and scored below average on staffing, personal care, and recreational activities., Conclusions: There was considerable variation between the participating LTCFs in the prevalence of APD use. Variability was related to LTCF characteristics and patient satisfaction. This indicates potential inappropriate prescribing because of differences in institutional prescribing culture.

In order to provide adequate care for frail older adults in primary care it is essential to have insight into their care needs. Our aim was to describe the met and unmet care needs as perceived by frail older adults using a multi-dimensional needs assessment, and to explore their associations with socio-demographic and health-related characteristics. Cross-sectional baseline data were used from the Frail older Adults: Care in Transition (ACT) study in the Netherlands, consisting of 1137 community dwelling frail older adults aged 65 and above. Patients were recruited through 35 primary care practices. Self-perceived care needs were assessed using the Camberwell Assessment of Need for the Elderly (CANE). Socio-demographic characteristics included age, sex, partner status and educational level. Health-related characteristics included functional capacity, hospital admissions, chronic diseases and the degree of frailty. Frail older adults reported on average 4.2 care needs out of 13 CANE topics, of which 0.5 were unmet. The physical and environmental domain constituted the highest number of needs, but these were mostly met. Unmet needs were mainly found in the psychosocial domain. Regression analyses revealed that Activities of Daily Living (ADL) limitations and a higher frailty score were the most important determinants of both met and unmet care needs. A younger age and a higher educational level were associated with the presence of unmet care needs. In conclusion, most frail older adults in primary care report to receive sufficient help for their physical needs. More attention should be paid to their psychosocial needs., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Analysis of a relationship between wandering and involvement in meaningful activities in nursing home residents with cognitive impairment., Design: Cross-sectional analysis of the minimum data set information., Setting: The analyses were conducted on 8 nursing homes in the Netherlands., Participants: The participants were residents aged 65 years and above with an evidence of cognitive impairment., Measurements: Items in the minimum data set related to wandering behavior, involvement in activities, presence of psychotic symptoms, and treatment with antipsychotics. Ambulatory residents who exhibited wandering were divided into: those whose behavior was easily altered [modifiable wandering (MW)] and those whose wandering behavior was not easily altered by the staff [nonmodifiable wandering (NMW)]. The duration of time for which they had opportunity to be involved in meaningful activities was estimated from involvement in activities of nonambulatory residents., Results: The prevalence of wandering increased with severity of cognitive impairment. MW was present in 3.5% of total residents (8.5% of ambulatory), whereas NMW was present in 11.2% of the total ambulatory and nonambulatory residents (26.6% of ambulatory). The risk of NMW was increased with resistiveness to care and decreased with antipsychotic use. Individuals with NMW were less involved in activities. NMW was more prevalent in facilities in which residents were involved in activities for a shorter duration., Conclusions: Involvement of residents in meaningful activities should be tested for reducing the incidence of problematic wandering and for decrease in usage of antipsychotic medications.

Objectives: Determine which behavioral syndromes of dementia are independently related to weight loss., Design: Longitudinal study using four subsequent quarterly Minimum Data Set (MDS) 2.0 assessments. Characteristics obtained in one period were related to weight loss observed in the next period., Setting: Eight nursing homes in the Netherlands., Participants: The initial population was 2031 nursing home residents with four quarterly MDS assessments within a period of 15 months. We selected 1850 subjects who were at least 65 years old at the time of the first assessment and who were not comatose., Measurements: Information about the presence of four behavioral syndromes (depression, apathy, agitation, and rejection of care), demographic data, cognition status, body mass index (BMI), and time that residents were involved in activities were obtained from MDS 2.0., Results: Bivariate correlation showed that weight loss at follow-up assessments was related to all baseline behavioral syndromes, degree of cognitive impairment, body mass index, and time that residents were involved in activities. Multivariable binary logistic regression with these factors showed that the only behavioral syndrome that was independently related to subsequent weight loss was apathy. In multivariable analysis, the degree of cognitive impairment and BMI were also independently related to weight loss., Conclusion: These results suggest that of all behavioral factors we have assessed, apathy had the strongest association with weight loss in nursing home residents even when adjusted for the degree of cognitive impairment., (Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Performance indicators in the long term care sector are important to evaluate the efficiency and quality of care delivery. We are, however, still far from being able to refer to a common set of indicators at the European level.We therefore demonstrate the calculation of Long Term Care Facility Quality Indicators (LTCFQIs) from data of the European Services and Health for Elderly in Long TERm Care (SHELTER) project. We explain how risk factors are taken into account and show how LTC facilities at facility and country level can be compared on quality of care using thresholds and a Quality Indicator sum measure., Methods: The indicators of Long Term Care Facility quality of care are calculated based on methods that have been developed in the US. The values of these Quality Indicators (QIs) are risk adjusted on the basis of covariates resulting from logistic regression analysis on each of the QIs. To enhance the comparison of QIs between facilities and countries we have used the method of percentile thresholds and developed a QI sum measure based on percentile outcomes., Results: In SHELTER data have been collected with the interRAI Long Term Care Facility instrument (interRAI-LTCF). The data came from LTC facilities in 7 European countries and Israel. The unadjusted values of the LTCF Quality Indicators differ considerably between facilities in the 8 countries. After risk adjustment the differences are less, but still considerable. Our QI sum measure facilitates the overall comparison of quality of care between facilities and countries., Conclusions: With quality indicators based on assessments with the interRAI LTCF instrument quality of care between LTC facilities in and across nations can be adequately compared.

Objective: To compare the prevalence of diagnosed depressive disorders, depressive symptoms and use of antidepressant medication between nursing home residents with and without dementia., Methods: This cross-sectional study used Minimal Data Set of the Resident Assessment Instrument 2.1 data collected in seven nursing homes located in an urbanized region in the Netherlands. Trained nurse assistants recorded all medical diagnoses made by a medical specialist, including dementia and depressive disorder, and medication use. Depressive symptoms were measured with the Depression Rating Scale. Multivariate logistic regression analysis was used to compare data between residents with and without dementia., Results: Included in the study were 1885 nursing home residents (aged 65 years or older), of which 837 had dementia. There was no significant difference in the prevalence of diagnosed depressive disorder between residents with (9.6%) and without dementia (9.8%). Residents with dementia (46.4%) had more depressive symptoms than residents without dementia (22.6%). Among those with depressive symptoms, residents with dementia had the same likelihood of being diagnosed with a depressive disorder as residents without dementia. Among residents with a diagnosed depressive disorder, antidepressant use did not differ significantly between residents with dementia (58.8%) and without dementia (57.3%). The same holds true for residents with depressive symptoms, where antidepressant use was 25.3% in residents with dementia and 24.6% in residents without dementia., Conclusions: Regarding the prevalence rates of diagnosed depressive disorder and antidepressant use found in this study, our findings demonstrate that there is room for improvement not only for the detection of depression but also with regard to its treatment., (Copyright © 2012 John Wiley & Sons, Ltd.)

Background: many instruments are available to identify frail older adults who may benefit from geriatric interventions. Most of those instruments are time-consuming and difficult to use in primary care., Objective: to select a valid instrument to identify frail older adults in primary care, five simple instruments were compared., Methods: instruments included clinical judgement of the general practitioner, prescription of multiple medications, the Groningen frailty indicator (GFI), PRISMA-7 and the self-rated health of the older adult. Fried's frailty criteria and a clinical judgement by a multidisciplinary expert panel were used as reference standards. Data were used from the cross-sectional Dutch Identification of Frail Elderly Study consisting of 102 people aged 65 and over from a primary care practice in Amsterdam. In this study, frail older adults were oversampled. We estimated the accuracy of each instrument by calculating the area under the ROC curve. The agreement between the instruments and the reference standards was determined by kappa., Results: frailty prevalence rates in this sample ranged from 11.6 to 36.4%. The accuracy of the instruments ranged from poor (AUC = 0.64) to good (AUC = 0.85)., Conclusion: PRISMA-7 was the best of the five instruments with good accuracy. Further research is needed to establish the predictive validity and clinical utility of the simple instruments used in this study.

Background: Successfully introducing and maintaining care innovations may depend on the interplay between care setting, the intervention and specific circumstances. We studied the factors influencing the introduction and maintenance of a Multidisciplinary Integrated Care model in 10 Dutch residential care homes., Methods: Facilitating and impeding factors were studied and compared at the time of introduction of the interRAI-LTCF assessment method in residential care homes as well as three years later, by surveys and semi structured interviews among nurse staff, managers, and physicians., Results: Facilitating factors at introduction were positive opinions of staff and family physicians about the changes of the process of care and the anticipated improvement of quality of care. Staff was positive about the applicability of the software to support the interRAI-LTCF assessments. Impeding factors were time constraints to complete interRAI-LTCF assessments and insufficient computer equipment.In the maintenance phase, the positive attitude of the location manager and the perceived benefits of the care model and the interRAI-LTCF assessment method were most important. Impeding factors after 3 years remained the lack of time to complete the assessments and lack of sufficient computer equipment., Conclusions: Impeding and facilitating factors were comparable in the initial and maintenance phase. Adoption of the interRAI-LTCF assessment method depended on positive opinions of staff and management, continuing support of staff and the availability of sufficient computer equipment.

Objective: To estimate and compare the prevalence and incidence of delirium and its risk factors in residents of Dutch nursing homes and residential care homes., Methods: Data were extracted from the Long-Term Care Facility (inter RAI-LTCF) version of the Resident Assessment Instrument, which was filled in a routine care cohort for a total of 3627 residents. 828 residents of six nursing homes and 1365 residents of 23 residential homes were included in the analyses. Delirium was defined as a positive score on the adjusted Nursing Home-CAM., Results: The prevalence of delirium was 8.9% in the nursing homes and 8.2% in the residential homes. The incidence was highest in the nursing homes with 20.7 versus 14.6 per 100 person-years. Multivariate tests of risk factors for developing delirium included chair restraints (OR 2.3; 95% CI 1.27-4.28), dementia (odds ratio (OR) 3.3; 95% confidence interval (CI) 2.03-5.24) and Parkinson's disease (OR 2.3; 95% CI 0.96-5.63) for residents in nursing homes, and dementia (OR 1.8; 95% CI 1.31-2.55) and fall incidents (OR 1.7; 95% CI 1.20-2.48) for residents in residential care homes., Conclusion: The prevalence and incidence of delirium was high in both nursing homes and residential care homes. More focus on modifiable risk factors such as the use of restraints in nursing homes and fall incidents in residential care homes may help to prevent delirium., (Copyright © 2011 John Wiley & Sons, Ltd.)

Objective: The aim of this study is to analyze modifiable factors related to agitation of nursing home residents with dementia., Methods: Relationship of agitation with three modifiable factors (depression, psychosis, and pain) was explored using longitudinal Minimum Data Set (MDS) information from 2032 residents of Dutch nursing homes. Presence of agitation and depression was ascertained using validated scales based on MDS information. Presence of psychosis and pain was ascertained from the individual MDS items., Results: There was a significant correlation between MDS depression and agitation scores. Depression scores increased in residents whose agitation worsened and decreased in residents whose agitation improved. Psychosis scores (combination of delusions and hallucinations) also correlated with MDS depression scores, and psychosis scores increased in residents whose agitation worsened. Pain scores correlated with agitation scores, but the pain scores did not change with changes in agitation. Depression symptoms were present in 51% of residents, while psychotic symptoms were present only in 15% of residents, and two-thirds of these residents were also depressed., Conclusion: These results indicate that depression may be the most common factor associated with agitation in nursing home residents with dementia., (Copyright © 2011 John Wiley & Sons, Ltd.)

Objective: The objective of this study was to evaluate the cost-effectiveness of a Multidisciplinary Integrated Care (MIC) model compared to Usual Care (UC) in Dutch residential homes., Methods: The economic evaluation was conducted from a societal perspective alongside a 6 month, clustered, randomized controlled trial involving 10 Dutch residential homes. Outcome measures included a quality of care weighted sum score, functional health (COOP WONCA) and Quality Adjusted Life-Years (QALY). Missing cost and effect data were imputed using multiple imputation. Bootstrapping was used to analyze differences in costs and cost-effectiveness., Results: The quality of care sum score in MIC was significantly higher than in UC. The other primary outcomes showed no significant differences between the MIC and UC. The costs of providing MIC were approximately €225 per patient. Total costs were €2,061 in the MIC group and €1,656 for the UC group (mean difference €405, 95% -13; 826). The probability that the MIC was cost-effective in comparison with UC was 0.95 or more for ceiling ratios larger than €129 regarding patient related quality of care. Cost-effectiveness planes showed that the MIC model was not cost-effective compared to UC for the other outcomes., Interpretation: Clinical effect differences between the groups were small but quality of care was significantly improved in the MIC group. Short term costs for MIC were higher. Future studies should focus on longer term economic and clinical effects., Trial Registration: Controlled-Trials.com ISRCTN11076857.

Background: Sophisticated approaches are needed to improve the quality of care for elderly people living in residential care facilities. We determined the effects of multidisciplinary integrated care on the quality of care and quality of life for elderly people in residential care facilities., Methods: We performed a cluster randomized controlled trial involving 10 residential care facilities in the Netherlands that included 340 participating residents with physical or cognitive disabilities. Five of the facilities applied multidisciplinary integrated care, and five provided usual care. The intervention, inspired by the disease management model, consisted of a geriatric assessment of functional health every three months. The assessment included use of the Long-term Care Facility version of the Resident Assessment Instrument by trained nurse-assistants to guide the design of an individualized care plan; discussion of outcomes and care priorities with the family physician, the resident and his or her family; and monthly multidisciplinary meetings with the nurse-assistant, family physician, psychologist and geriatrician to discuss residents with complex needs. The primary outcome was the sum score of 32 risk-adjusted quality-of-care indicators., Results: Compared with the facilities that provided usual care, the intervention facilities had a significantly higher sum score of the 32 quality-of-care indicators (mean difference - 6.7, p = 0.009; a medium effect size of 0.72). They also had significantly higher scores for 11 of the 32 indicators of good care in the areas of communication, delirium, behaviour, continence, pain and use of antipsychotic agents., Interpretation: Multidisciplinary integrated care resulted in improved quality of care for elderly people in residential care facilities compared with usual care., Trial Registration: www.controlled-trials.com trial register no. ISRCTN11076857.

Background: The behaviour of individuals is affected by the social networks in which they are embedded. Networks are also important for the diffusion of information and the influence of employees in organisations. Yet, at the moment little is known about the social networks of nursing staff in healthcare settings. This is the first study that investigates informal communication and advice networks of nursing staff in long-term care. We examine the structure of the networks, how they are related to the size of units and characteristics of nursing staff, and their relationship with job satisfaction., Methods: We collected social network data of 380 nursing staff of 35 units in group projects and psychogeriatric units in nursing homes and residential homes in the Netherlands. Communication and advice networks were analyzed in a social network application (UCINET), focusing on the number of contacts (density) between nursing staff on the units. We then studied the correlation between the density of networks, size of the units and characteristics of nursing staff. We used multilevel analyses to investigate the relationship between social networks and job satisfaction of nursing staff, taking characteristics of units and nursing staff into account., Results: Both communication and advice networks were negatively related to the number of residents and the number of nursing staff of the units. Communication and advice networks were more dense when more staff worked part-time. Furthermore, density of communication networks was positively related to the age of nursing staff of the units. Multilevel analyses showed that job satisfaction differed significantly between individual staff members and units and was influenced by the number of nursing staff of the units. However, this relationship disappeared when density of communication networks was added to the model., Conclusions: Overall, communication and advice networks of nursing staff in long-term care are relatively dense. This fits with the high level of cooperation that is needed to provide good care to residents. Social networks are more dense in small units and are also shaped by characteristics of staff members. The results furthermore show that communication networks are important for staff's job satisfaction.

Background: Social engagement and depression are important outcomes for residents with dementia in long-term care. However, it is still largely unclear which differences in social engagement and depression exist in residents of various long-term care settings and how these differences may be explained. This study investigated the relationship between social engagement and depressive symptoms in long-term care dementia units, and studied whether differences in social engagement and depressive symptoms between units can be ascribed to the composition of the resident population or to differences in type of care setting., Methods: Thirty-seven long-term care units for residents with dementia in nursing- and residential homes in the Netherlands participated in the study. Social engagement and depressive symptoms were measured for 502 residents with the Minimum Data Set of the Resident Assessment Instrument. Results were analyzed using multilevel analysis., Results: Residents of psychogeriatric units in nursing homes experienced low social engagement. Depressive symptoms were most often found in residents of psychogeriatric units in residential homes. Multilevel analyses showed that social engagement and depressive symptoms correlated moderately on the level of the units. This correlation disappeared when the characteristics of residents were taken into account., Conclusions: Social engagement and depressive symptoms are influenced not only by individual characteristics but also by the type of care setting in which residents live. However, in this study social engagement and depressive symptoms were not strongly related to each other, implying that separate interventions are needed to improve both outcomes.

Objective: Although community-based studies reported an increased incidence of depression among demented persons compared with non-demented persons, it is not clear whether this relationship also exists among institutionalised elderly persons. The aim of this study was to compare the prevalence of diagnosed depressive disorders and mood symptoms between demented and non-demented residents living in Dutch homes for the elderly., Methods: Cross-sectional analysis in 16 homes for the elderly of routine outcome measurements by trained nurse assistants using the Resident Assessment Instrument (RAI) between January 2007 and April 2008. Nurse assistants recorded all known medical diagnoses including dementia and depression, as well as a structured observation of the presence or absence of 11 mood symptoms over the last 3 days., Results: 313 demented and 463 non-demented residents with complete data were included (99% of all residents, mean age 84 years). 24.6% of participants were diagnosed with a depressive disorder, with no statistically significant difference between demented and non-demented persons (p = 0.237). Mood symptoms were more prevalent in demented residents (p < 0.001, OR 2.14, 95%CI 1.56-2.93). Among residents with mood symptoms, demented residents were less likely to be diagnosed with a depressive disorder than non-demented residents (p = 0.039, OR 0.61, 95%CI 0.38-0.98)., Conclusions: The prevalence of diagnosed depressive disorders was comparable between demented and non-demented residents. However, demented residents suffered more from mood symptoms and may be at risk of under-diagnosis of depression., ((c) 2009 John Wiley & Sons, Ltd.)

Aims and Objectives: The aim of this study was to develop an observational scale to measure the social well-being of nursing home residents, by assessing not only the social behaviour of the resident towards others, but also the behaviour of others towards the resident., Background: Traditionally, aspects of the social well-being of nursing home residents are assessed according to the social activities and interactions where they engage. Although these are important indicators of social well-being, other important indicators may include the positive social behaviour of others towards the resident (e.g. confirming the resident's behaviour or showing affection)., Design: A cross-sectional descriptive survey design., Method: From the perspective of human social needs, items relating to fulfillment of the needs for affection, behavioural confirmation and status were formulated and tested. This took place in three nursing homes in the Netherlands that provide somatic and psycho-geriatric care., Results: The study (sample n = 306) yielded a short and reliable scale, the Social Well-being Of Nursing home residents-scale, with separate sub-scales (three items each) for fulfillment of the three social needs., Conclusions: These first results indicate that overall social well-being and its sub-dimensions can be measured with this new observational scale, although its validity needs to be confirmed. Including the social behaviour of others towards the resident may have provided a more comprehensive measure of the social well-being of nursing home residents., Relevance to Clinical Practice: This measure may help to underscore the importance of the social behaviour of others (e.g. caregivers) for the overall social well-being of residents and with that assist care-providers in nursing homes to improve the social well-being of the residents.

Objectives: To determine modifiable factors related to abusive behaviors in nursing home residents with dementia., Design: Analysis of Minimum Data Set (MDS) of the Resident Assessment Instrument (RAI) information., Setting: We used MDS-RAI data from 8 Dutch nursing homes and 10 residential homes that volunteered to collect data for care planning. We included the data of residents within a 12-month time window for each facility separately, resulting in a range from April 4, 2007, to December 1, 2008., Participants: We selected 929 residents older than 65 with Alzheimer's disease or other dementia who were dependent in decision making and not comatose., Measurements: Cognitive Performance Scale, MDS Depression Scale and several individual items from the MDS-RAI (ability to understand others, verbally and physically abusive behavioral symptoms, resist care, diagnosis of Alzheimer's disease and of dementia other than Alzheimer's disease, diagnosis of depression, presence of delusions, hallucinations, pain frequency and constipation, and number of days receiving medications)., Results: Resistiveness to care, related to lack of understanding, depression, hallucinations and delusions, was strongly related to abusive behaviors. Presence of depressive symptoms and delusions was also related to abusive behaviors independent of resistiveness to care. Only very few residents who understood others and were not depressed were abusive., Conclusion: Abusive behaviors may develop from lack of understanding leading to resistiveness to care. Behavioral interventions preventing escalation of resistiveness to care into combative behavior and the treatment of depression can be expected to decrease or prevent abusive behavior of most nursing home residents with dementia.

Background and Objective: Many patients who suffer from an acute stroke, will need long-term nursing home care. We are poorly informed about the demographic and clinical characteristics and about the care problems and received care of these patients. This study aims to provide a first description of these characteristics in this group of patients., Methods: Data on demographic and health-related characteristics, social participation and received care were collected with the Minimum Data Set of the Resident Assessment Instrument, from january 2004-march 2007, in patients who needed long-term nursing home care. Data were collected in eight nursing homes at admission and six months after admission., Results: Many patients were functionally impaired, suffered from depressive symptoms and pain, and were cognitively impaired. In addition, decisional capacity was frequently diminished. The majority of patients were residing at somatic wards, even when severe cognitive impairment was present, such as dementia. Several forms of restraints were frequently used, also at somatic wards. About 40% of the patients, mostly residing at somatic wards, received paramedical treatment. Social engagement was low and was correlated with functional impairment., Conclusions: Stroke patients who need long-term nursing home care suffer from problems in several domains. The high prevalence of cognitive impairment in stroke patients residing at somatic wards, combined with the ample use of restraints on these wards, raises questions about the appropriateness of the currently delivered care to these patients, considering the problems they have.

Background: The objective of this article is to describe the design of a study to evaluate the clinical and economic effects of a Disease Management model on functional health, quality of care and quality of life of persons living in homes for the elderly., Methods: This study concerns a cluster randomized controlled clinical trial among five intervention homes and five usual care homes in the North-West of the Netherlands with a total of over 500 residents. All persons who are not terminally ill, are able to be interviewed and sign informed consent are included. For cognitively impaired persons family proxies will be approached to provide outcome information. The Disease Management Model consists of several elements: (1) Trained staff carries out a multidimensional assessment of the patients functional health and care needs with the interRAI Long Term Care Facilities instrument (LTCF). Computerization of the LTCF produces immediate identification of problem areas and thereby guides individualized care planning. (2) The assessment outcomes are discussed in a Multidisciplinary Meeting (MM) with the nurse, primary care physician, nursing home physician and Psychotherapist and if necessary other members of the care team. The MM presents individualized care plans to manage or treat modifiable disabilities and risk factors. (3) Consultation by an nursing home physician and psychotherapist is offered to the frailest residents at risk for nursing home admission (according to the interRAI LTCF). Outcome measures are Quality of Care indicators (LTCF based), Quality Adjusted Life Years (Euroqol), Functional health (SF12, COOP-WONCA), Disability (GARS), Patients care satisfaction (QUOTE), hospital and nursing home days and mortality, health care utilization and costs., Discussion: This design is unique because no earlier studies were performed to evaluate the effects and costs of this Disease Management Model for disabled persons in homes for the elderly on functional health and quality of care. TRAIL REGISTRATION NUMBER: ISRCTN11076857.

Introduction: Earlier cross-sectional research in the Netherlands has found that one out of three nursing home patients has a pressure ulcer. The prevalence of other ulcers is unknown., Methods: In eight nursing homes 2295 patients were assessed with the Minimum Data Set (MDS). The mean age of the patients was 82.9 years (SD 7.4) and 70% was female. One third had severe cognitive impairment and only 17% had no or little ADL impairment., Results: Prevalence of pressure ulcers was: stage 1: 3,6%; stage 2: 2,5%; stage 3: 1,2%; stage 4: 0,8%. Having a pressure ulcer was strongly correlated with ADL dependency: Odds Ratio (OR) 8,4 for moderate ADL-dependency, and OR 35,4 for severe ADL-dependency. Patients with pressure ulcers had more often pain (OR 2,7) and depressive symptoms (OR 2,1). Bowel incontinence was significantly correlated (OR 2,6) with pressure ulcers, just as the presence of an indwelling catheter (OR 3,2) and the use of diapers (OR 2,2), but urinary incontinence was not correlated with pressure ulcers. The prevalence of a venous ulcers was 2,6% and 1,7% had a venous ulcer higher than stage 1. The combination of foot ulcers and diabetes occurred in 1,2%, the combination of a peripheral vascular disease and ulcers in only 0,7%. The use of pressure reducing interventions increased with ADL dependency, nevertheless only 44% of the very dependent patients used these interventions.

The objective of this study was to improve validity and reliability estimates of the Index for Social Engagement (ISE) for long-term care. After exploring content validity and internal consistency in Dutch and Canadian data, two ISE items were dropped, and two new items were added. Reliability of this Revised ISE (RISE) was tested in 189 nursing home residents. It appeared that the RISE has enhanced reliability estimates, especially in residents with cognitive impairment. The RISE for long-term care improves the existing index by including additional dimensions of social engagement and by increasing the reliability of results for residents with cognitive impairment.

Objectives: To describe and calculate Home Care Quality Indicators from data of the European Aged in Home Care (ADHOC) project. With due regard for risk factors, home care agencies at country level have been compared with each other on quality of care., Methods: The indicators of Home Care quality of care (HCQIs) are calculated based on methods that have been developed in the US and Canada. The values of these QIs are risk adjusted on the basis of odds ratios of covariates resulting from logistic regression analysis on the ADHOC sample. To enhance the comparison of QIs between countries we have used the method of percentile thresholds and QI aggregate sum measure related to those., Results: Risk adjusted values of 22 Home Care Quality Indicators differed considerably between home care agencies in the eleven European countries that participated in ADHOC. The QI aggregate showed which countries probably had the best home care and which had the worst., Conclusions: There are quality indicators available, derived from data of the Resident Assessment Instrument for Home Care, with which quality of care between home care agencies in and across nations can be adequately compared. Examples of this type of indicator are: social isolation, inadequate pain control, failure to improve in impaired locomotion in the home.

The objective was to construct a reliable and valid challenging behavior scale with items from the Minimum Data Set (MDS). Exploratory factor analyses of a sample of 656 nursing home residents yielded a 16-item Behavior Profile containing four internally consistent and valid subscales measuring conflict behavior, withdrawn behavior, agitation and attention seeking behavior (alpha range: 0.69-0.80). On a second dataset of 227 nursing home residents, internal consistency, inter-rater reliability and validity against the Behavior Rating Scale for Psychogeriatric Inpatients (GIP) were established. Internal consistency of the subscales ranged between 0.54 and 0.78. The overall inter-rater reliability of the items was 0.53 (kappa); of the scale it was 0.75 (ICC). The MDS Challenging Behavior Profile could potentially be an important contribution to existing clinical MDS-scales but additional studies on reliability, validity and usefulness are needed.

Objective: Prognostic information is important for guiding palliative care planning for patients with dementia. We aim to validate a risk score that uses Minimum Data Set (MDS) to estimate 6-month mortality for nursing home residents with advanced dementia., Design: Two cohort studies., Setting: Six nursing homes in The Netherlands, and 35 nursing homes in Missouri., Participants: Long-term stay residents with advanced dementia: 288 Dutch residents and 269 residents from Missouri who also had a lower respiratory tract infection (LRI)., Measurements: Patient risk factors and 6-month mortality., Results: Six-month mortality rates were 24.3% for Dutch residents, and 36.8% for US residents. The risk score's AUROC was 0.65 (CI 0.58-0.72), and 0.64 (CI 0.58-0.71), respectively. For the large majority of residents, observed mortality in the 2 validation cohorts were comparable to the development cohort. Among the few residents identified as at very high risk according to the risk score, observed mortality was lower than expected., Conclusion: The original mortality risk score predicted 6-month mortality with reasonable accuracy in 2 validation cohorts of nursing home residents with advanced dementia. Thus, the performance of the risk score, at least over the range of low to moderate risk (up to around 40% risk of mortality), can be generalized to long-stay (versus recently admitted) residents with advanced dementia, and to those with LRI.

Data to determine the resource utilization of care recipients need to be reliable and the items that are measured need to be useful. In 2006, the Dutch Ministry of Health and Welfare has mandated all nursing homes and homes for the elderly to measure the Resource Utilization of all residents with the ZZP Questionnaire. Are the data resulting from this measurement reliable and is each of the 54 items of the ZZP Questionnaire useful? To answer this we tested the reliability of the data in a nursing home and a home for the elderly in two wards each. For 122 residents questionnaires were completed such that the inter- and intra-rater reliability of the answers could be assessed. Ten of the 54 items in the questionnaire showed insufficient inter rater reliability (<0.40) on the weighted Cohen kappa and another sixteen moderate (0.40 - 0.60). On the intra rater reliability test seven items had an insufficient kappa and another fifteen moderate. Besides, ten clusters of items could be formed with in-cluster Spearman correlation rates of .75 or higher. From the results of the reliability tests and the item intercorrelation rates we concluded that a substantial number of items needs to be improved and that in the ZZP Questionnaire 15 of the 54 items appear to be redundant on statistical grounds.

Objective: To determine the number of older people with acquired dual sensory impairment (DSI) in The Netherlands., Design: Combination of studies in the general population and in relevant subpopulations., Method: Eight databases derived from recent studies on older persons with vision and hearing data on Dutch subjects aged 55 years or over were selected for further analysis. The measurement methods included self-reports, clinical measurements and observations. The prevalences of DSI were calculated for the general population, the non-institutionalised population, and subgroups such as older people in nursing homes and homes for the elderly. The calculated prevalences were extrapolated to the overall Dutch population., Results: For the non-institutionalised population of 55 years and older, the prevalences of acquired DSI in two different data sets were 0.4% (95% CI: 0.2-0.6) and 0.6% (95% CI: 0.3-0.8), respectively. Among the inhabitants of homes for the elderly these percentages were 5.4% (95% CI: 0.9-9.9) and 5.5% (95% CI: 3.8-7.2), and in nursing homes they were 12.7% (95% CI: 9.7-15.7) and 16.7% (95% CI: 14.6-18.8). Acquired DSI was most common in persons 85 years of age and older. It was estimated that the number of people aged 55 years and over with acquired DSI in The Netherlands is 30,000 to 35,000., Conclusion: DSI is particularly a problem of the oldest old. An integrated approach to the visual and hearing problems of these subjects is essential.

Objectives: To investigate the effect of chronic diseases and disease combinations on 1-year mortality in nursing home residents., Design: Retrospective cohort study using electronically submitted Minimum Data Set (MDS) information and Missouri death certificate data., Setting: Five hundred twenty-two nursing homes in Missouri., Participants: Forty-three thousand five hundred ten nursing home residents with a full MDS assessment in 1999., Measurements: Information about chronic diseases, age, sex, and performance in activities of daily living (ADLs) available from the first full MDS 2.0 assessment in 1999; death within 1 year after the first full MDS-assessment in 1999., Results: After adjustment for age and sex, eight variables were predictive for 1-year mortality: seven chronic diseases (dementia, cancer, heart failure, renal failure, emphysema/chronic obstructive pulmonary disease, diabetes mellitus, and anemia) and an interaction variable containing age and cancer. Adding terms for disease combinations (e.g., diabetes mellitus and heart failure) did not enhance survival prediction. When there was also adjustment for ADL performance as measured using the MDS-ADL Short Form, dementia and anemia were not included, because they had no prognostic value above that of the other variables., Conclusion: Several chronic diseases were associated with 1-year mortality in the institutionalized elderly after adjustment for ADL performance, age, and sex. Evidence of a synergistic effect of disease combinations on mortality is lacking.

Large numbers of persons in most types of healthcare settings have palliative care needs that have considerable impact on their quality of life. Therefore, InterRAI, a multinational consortium of researchers, clinicians, and regulators that uses assessment systems to improve the care of elderly and disabled persons, designed a standardized assessment tool, the Resident Assessment Instrument for Palliative Care (RAI-PC). The RAI-PC can be used for both the design of individual care plans and for case mix and outcomes research. Some elements of this instrument are taken from the resident assessment instrument (RAI) mandated for use in all nursing homes in the United States and widely used throughout the world. The RAI-PC can be used alone or in counjunction with the other assessment tools designed by the InterRAI collaboration: the RAI for homecare (RAI-HC), for acute care (RAI-AC), and for mental health care (RAI-MH). The objective of this study was to field test and carry out reliability studies on the RAI-PC. After appropriate approvals were obtained, the RAI-PC instrument was field tested on 151 persons in three countries in more than five types of settings. Data obtained from 144 of these individuals were analyzed for reliability. The reliability of the instrument was very good, with about 50 percent of the questions having kappa values of 0.8 or higher, and the average kappa value for each of the eight domains ranging from 0.76 to 0.95. The 54 men and 95 women had a mean age of 79 years. Thirty-four percent of individuals suffered pain daily. Eighty percent tired easily; 52 percent were breathless on exertion; and 19 to 53 percent had one or more other symptoms, including change in sleep pattern, dry mouth, nausea and vomiting, anorexia, breathlessness at rest, constipation, and diarrhea. The number of symptoms an individual reported increased as the estimated time until death declined. The "clinician friendly" RAI-PC can be used in multiple sites of care to facilitate both care planning and case mix and outcomes research.

Objectives: To develop a scale predicting mortality and other adverse outcomes associated with frailty., Design: Observational study based on Minimum Data Set (MDS) 2.0 and mortality data., Setting: Ontario chronic hospitals., Participants: All chronic hospital patients (N = 28,495) assessed with the MDS 2.0 after mandatory implementation in July 1996 followed until May 1999., Measurements: MDS 2.0 assessments done as part of normal practice mainly by registered nurses or multidisciplinary teams in a chronic hospital. Mortality data are available from the accompanying discharge tracking form., Results: The MDS-Changes in Health, End-stage disease and Symptoms and Signs (CHESS) score is a composite measure addressing changes in health, end-stage disease, and symptoms and signs of medical problems. It is a strong predictor of mortality (P <.0001) independent of the effects of age, sex, activities of daily living impairment, cognition, and do-not-resuscitate orders. It is also strongly associated with physician activity, complex medical procedures, and pain (P <.001 for each dependent variable)., Conclusions: The CHESS score provides a useful new MDS-based test to predict mortality and to measure instability in health as a clinical outcome.

This article is a descriptive study of the characteristics of nursing home day-care patients in the Netherlands in 1995 at first admission and at discharge. Data were derived from the National Nursing Home Registration System (SIVIS), in which in 1995 over 85% of Dutch nursing homes participated. Newly admitted day-care patients are characterized by high age (89% older than 65 years), a distribution with (only!) 9% more women than men and a morbidity pattern of chronic somatic (cerebrovascular disease 45%) and psychogeriatric (dementia 80%) disorders. This morbidity pattern was associated with a considerable degree of disability, in particular regarding the activities of daily living and mobility. Most patients (78%) come from their own homes. The average length of stay from admittance to discharge, for both somatic and psychogeriatic day-care patients was nine months. For about 10% of the somatic patients and 40% of the psychogeriatic ones ambulatory day-care resulted in (subsequent) admission to the nursing home itself. In the last decade nursing home day-care capacity has increased rapidly and parallel to this also the number of day-care patients. Remarkably the average level of disability and the average period of treatment of nursing home day-care patients has remained approximately the same in this period.

Objective: To determine the characteristics of patients during stay in nursing homes, and at the moment of discharge or death., Design: Cross-sectional study., Method: Data were collected concerning September 30th 1991 using the National Nursing Home Registration System SIVIS, in which over 80% of the nursing homes participate. There were 45,471 patients (23,395 somatic and 22,076 psychogeriatric patients)., Results: Frequent morbidity consisted of stroke, neurological disorders, locomotor disorders and dementia. There was a high degree of disability regarding the activities of daily life and mobility. The average length of stay for somatic patients was just over one year, that for psychogeriatric patients almost two and a half years. After rehabilitation, one-third of the patients could be discharged to their homes or to a home for the aged. (Most of the remaining patients eventually died in the nursing home.), Conclusion: Residing nursing home patients are mainly characterised by chronic disorders. Consequently, disabilities and handicaps occur in many areas, such as self-care, mobility and psychological functioning. For a number of patients the distinction between somatic or psychogeriatric nursing becomes irrelevant. For all categories of patients the utilisation of care resources is increasing.

Introduction: Some 35,000 new patients are admitted yearly to 'verpleeghuizen' or Dutch nursing homes. This paper describes some characteristics of these patients., Method: Data were collected using the national Nursing Home Registration System SIVIS of the Dutch centre for health care information. The response rate to the registration by the nursing homes is over 80%., Results: Newly admitted nursing home patients are characterised by a (very) high age (over 50% of the patients are 80 years and over), a distribution of twice as many women as men and a morbidity pattern of chronic somatic and psychogeriatric, as well as orthopaedic disorders., Conclusion: Among elderly patients the nursing home patients constitute of a heterogeneous purpose of admission and morbidity pattern. Nursing home care focuses on rehabilitation, long-term care and terminal care.

A comparative study has been carried out to determine the influence of the care needs of patients on work pressure of nursing staff in the nursing homes of Amsterdam, Rotterdam and The Hague. Data of nursing home patients, resident at specific dates in nursing homes in the three largest cities have been compared with data from the rest of the Netherlands, altogether more than 40,000 patients at the time. The data came from the Dutch Nursing Home Information System (SIVIS). The differences have been determined in care needs and the changes in care needs in recent years. Nursing home patients in the three largest cities appear to have lower care needs than patients in the rest of the country. The care needs of the patients in the large cities hardly changed from 1986 to 1989. In the rest of the Netherlands a clear increase has occurred in the care needs of somatic and of psychogeriatric patients in the same period. The care needs of the patients in the three largest cities therefore cannot explain a higher work pressure of nursing staff as compared to the situation in nursing homes elsewhere in the Netherlands.