Anke Persoon

Hospital Elder Life Program integrated in dutch hospital care: a pilot

To the Editor: Many hospitals in the Netherlands have geriatric support but still lack a hospital-wide mind-set toward proactive integrated care, prevention of functional decline in older hospitalized adults, and attention to subjective well-being in care, so the CareWell in Hospital (CWH) program was developed. CWH aims to improve functional status and attention to quality of life in hospital care by appointing trained volunteers, similar to the Hospital Elder Life Program (HELP), which is innovative in Dutch hospital care, but before disseminating and sustaining HELP in the Netherlands, it was necessary to modify the program to make it feasible for Dutch hospitals. The HELP program was introduced and adapted to the Netherlands as part of the CWH program. CWH comprises a first-stage screening of patients aged 70 and older for risk of delirium, physical decline, falls, and undernutrition by nurses, followed by a second-stage screening by a geriatric nurse, a CareWell plan including a medication review, in-hospital follow-up, and an updated CareWell plan at discharge. Additional components may include taking a medical history by proxy; having a geriatrician perform a comprehensive geriatric assessment; discussing a patient in a multidisciplinary meeting; and having trained volunteers perform therapeutic (cognitive) activities, nutritional assistance, or physical activities with patients (mobilization). The geriatric consultation team (GCT) also educates nurses and physicians. A pilot study was conducted to determine the feasibility of the CWH program and gathering the research data. The pilot consisted of a preand postintervention evaluation performed from July 2010 to May 2011 at the University Centre for Chronic Diseases Dekkerswald, Nijmegen, the Netherlands. From October 1, 2010, CWH was implemented on two wards mainly with individuals with chronic pulmonary obstructive disease (COPD). Feasibility was determined using a process evaluation of CWH program implementation and a (cost-)effectiveness evaluation. The degree of CWH program implementation was evaluated using data from records of meetings with program leaders; registered intervention elements provided to patients; and interviews conducted with patients, nurses, physicians, and the CWH intervention team (GCT and trained volunteers). To determine the feasibility of primary outcome measures for CWH effectiveness, data were gathered about delirium incidence (clinical judgment of a geriatrician), cognitive functioning (Mini-Mental State Examination), and physical functioning (Katz activities of daily living (ADLs)) at admission and discharge. To determine the feasibility of a cost-effectiveness evaluation, data on length of stay (LOS) were collected from electronic medical files and data on use of healthcare services 3 months after discharge were collected using a written questionnaire. Healthcare services included hospital admission, visits to a general practitioner, home care, institutionalization, and day care. Because of privacy concerns, it was impossible to gather data from healthcare insurers or providers. To determine the validity of Table 1. Characteristics of the Study Population: Implementation of Intervention Elements and Outcome Measures (N = 28)

How older people nurses assess cognitive function through daily observation

AIM To obtain knowledge and insight into how older people nurses observe the cognitive function of their patients. BACKGROUND In cases of cognitive decline not due to delirium, the daily observation of cognitive function by nurses has not been standardised in hospital wards specialised in the care of older people. DESIGN A qualitative study with purposive sampling and semi-structured interviews. Methods.  Data were obtained by interviewing 10 Dutch nursing experts in the field of cognitive function in older patients. The interviews were recorded, transcribed and analysed by two independent researchers. RESULTS All the respondents stated that daily observation of cognitive function yields valuable information. The concept of cognitive function was operationalised differently by institute and by nurse. Observation and reporting methods varied, as did the goals set by the nurses. Nurses reported using many days of observation to reach final judgements. CONCLUSIONS Observations of cognitive functioning should include several cognitive domains, be restricted to a few days of observation and aim to both contribute to medical diagnoses and guide nursing interventions. RELEVANCE TO CLINICAL PRACTICE Until a valid instrument becomes available, nursing staff must standardise daily observations themselves. This paper describes input to achieve this.

Agreement between the assessments of cognitive functioning of hospitalized geriatric patients by nurses on acute geriatric wards.

arrest, only four of whom were resuscitated. The mortality was higher in women than in men (58% vs 49%, Po.01), although incidence was higher in men than in women (14 vs 9 per 100,000, Po.001). Fatal cases were older than nonfatal ones (77 vs 65, Po .001) and were found more often in colder months than in warmer months (January, 60%, October, 46%, Po.02). The total number of deaths during bathing in Japan for 1999 to 2000 was estimated by adjusting the present result to the stratified national age distribution and using annual data obtained from the Tokyo Metropolitan Medical Examiner’s Office, where 22.3% (2,264/10,132) of all unnatural deaths in Tokyo were autopsied (Figure 1). The annual number of deaths during bathing in Japan is estimated to be 14,134. This figure is almost identical to the estimation based on the total number of drowning deaths in Japan (3,205) and the average proportion of drowning deaths to total deaths during bathing between 1990 and 1999 in Tokyo (22%) (3,205/0.22 5 14,568). Because three fourths of the victims were estimated to be aged 65 and older and the number exceeds the total deaths due to traffic accidents, death during bathing is a sociocultural challenge for the aged Japanese society.

Effects of substituting nurse practitioners, physician assistants or nurses for physicians concerning healthcare for the ageing population: a systematic literature review

AIMS To evaluate the effects of substituting nurse practitioners, physician assistants or nurses for physicians in long-term care facilities and primary healthcare for the ageing population (primary aim) and to describe what influences the implementation (secondary aim). BACKGROUND Healthcare for the ageing population is undergoing major changes and physicians face heavy workloads. A solution to guarantee quality and contain costs might be to substitute nurse practitioners, physician assistants or nurses for physicians. DESIGN A systematic literature review. DATA SOURCES PubMed, EMBASE, CINAHL, PsycINFO, CENTRAL, Web of Science; searched January 1995-August 2015. REVIEW METHODS Study selection, data extraction and quality appraisal were conducted independently by two reviewers. Outcomes collected: patient outcomes, care provider outcomes, process of care outcomes, resource use outcomes, costs and descriptions of the implementation. Data synthesis consisted of a narrative summary. RESULTS Two studies used a randomized design and eight studies used other comparative designs. The evidence of the two randomized controlled trials showed no effect on approximately half of the outcomes and a positive effect on the other half of the outcomes. Results of eight other comparative study designs point towards the same direction. The implementation was influenced by factors on a social, organizational and individual level. CONCLUSION Physician substitution in healthcare for the ageing population may achieve at least as good patient outcomes and process of care outcomes compared with care provided by physicians. Evidence about resource use and costs is too limited to draw conclusions.

Development and Validation of the Geriatric In‐Hospital Nursing Care Questionnaire

To develop a questionnaire, the Geriatric In‐hospital Nursing Care Questionnaire (GerINCQ), to measure, in an integrated way, the care that older adults receive in the hospital and nurses’ attitudes toward and perceptions about caring for older adults.

Physician substitution by mid-level providers in primary healthcare for older people and long-term care facilities: protocol for a systematic literature review

AIM This protocol describes a systematic review that evaluates the effects of physician substitution by mid-level providers (nurse practitioners, physician assistants or nurses) in primary healthcare for older people and long-term care facilities. The secondary aim is to describe facilitators and barriers to the implementation of physician substitution in these settings. BACKGROUND Healthcare for older people is undergoing major changes, due to population ageing and reforms that shift care to the community. Besides, relatively few medical students are pursuing careers in healthcare for older people. Innovative solutions are needed to guarantee the quality of healthcare and to contain costs. A solution might be shifting care from physicians to mid-level providers. To date, no systematic review on this topic exits to guide policymaking. DESIGN A quantitative systematic literature review using Cochrane methods. METHODS The following databases will be searched for original research studies that quantitatively compare care provided by a physician to the same care provided by a mid-level provider: PubMed, EMBASE, CINAHL, PsycINFO, CENTRAL and Web of Science. Study selection, data extraction and quality appraisal will be conducted independently by two reviewers. Data synthesis will consist of a qualitative analysis of the data. Funding of the review was confirmed in August 2013 by the Ministry of Health, Welfare and Sport of the Netherlands. DISCUSSION This review will contribute to the knowledge on effects of physician substitution in healthcare for older people and factors that influence the outcomes. This knowledge will guide professionals and policy administrators in their decisions to optimize healthcare for older people.

Evidence from Multicomponent Interventions: Value of Process Evaluations

1. Reimers MS, Bastiaannet E, van Herk-Sukel MPP et al. Aspirin use after diagnosis improves survival in older adults with colon cancer: A retrospective cohort study. J Am Geriatr Soc 2012;60:2232–2236. 2. Greystoke A, Mullamitha SA. How many diseases are colorectal cancer? Gastroenterol Res Pract 2012;2012:564741. 3. Liao X, Lochhead P, Nishihara R et al. Aspirin use, tumor PIK3CA mutation, and colorectal-cancer survival. N Engl J Med 2012;367:1596–1606. 4. Rothwell PM. Aspirin in prevention of sporadic colorectal cancer: Current clinical evidence and overall balance of risks and benefits. Recent Results Cancer Res 2013;191:121–142.

Uniform presentation of process evaluation results facilitates the evaluation of complex interventions: development of a graph

Rationale, aims and objectives Process evaluation is a highly essential element for the increasing number of studies regarding multi-component interventions. Yet, researchers are challenged to collect and present appropriate process outcomes in such way that it is easy and valuable to be used by other researchers and policy makers in interpreting and comparing intervention effects because of the absence of standards for conducting and publishing process evaluation. This article describes the development of a method to concisely summarize the results of process evaluations of complex multi-component interventions. Methods Development of a graph with the aim to facilitate the reporting of process evaluations results, based on a narrative review of the literature for process measures used in complex interventions for elderly people. Results Seventeen articles of process evaluations alongside effect studies of complex interventions were reviewed. From these articles, it was found that process evaluations should address whether the intervention (1) was implemented successfully; (2) was evaluated properly; and (3) can be continued in the future. A flow chart based on the essential components of an adequate process evaluation was developed. A simplified but highly informative figure reporting a summary of the results of the process evaluation is proposed and its use is explained by administering the figure to two studies including a process and effect evaluation of a complex intervention. Conclusion A graphical approach – which includes the core results of process evaluation and can be used directly in reporting effectiveness studies – will help researchers and policy makers to interpret and compare effects of complex multi-component interventions.RATIONALE, AIMS AND OBJECTIVES Process evaluation is a highly essential element for the increasing number of studies regarding multi-component interventions. Yet, researchers are challenged to collect and present appropriate process outcomes in such way that it is easy and valuable to be used by other researchers and policy makers in interpreting and comparing intervention effects because of the absence of standards for conducting and publishing process evaluation. This article describes the development of a method to concisely summarize the results of process evaluations of complex multi-component interventions. METHODS Development of a graph with the aim to facilitate the reporting of process evaluations results, based on a narrative review of the literature for process measures used in complex interventions for elderly people. RESULTS Seventeen articles of process evaluations alongside effect studies of complex interventions were reviewed. From these articles, it was found that process evaluations should address whether the intervention (1) was implemented successfully; (2) was evaluated properly; and (3) can be continued in the future. A flow chart based on the essential components of an adequate process evaluation was developed. A simplified but highly informative figure reporting a summary of the results of the process evaluation is proposed and its use is explained by administering the figure to two studies including a process and effect evaluation of a complex intervention. CONCLUSION A graphical approach - which includes the core results of process evaluation and can be used directly in reporting effectiveness studies - will help researchers and policy makers to interpret and compare effects of complex multi-component interventions.

Feeling useful and engaged in daily life: exploring the experiences of people with young-onset dementia

BACKGROUND To explore the aspects of daily life that give people with young-onset dementia (YOD) a sense of usefulness. METHODS Eighteen people with YOD and 21 informal caregivers participated in this qualitative study. Participants were recruited from specialized day-care centers for people with YOD in the Netherlands. Four focus groups were conducted with people with YOD, and four with informal caregivers. Focus groups were audio-recorded, transcribed, and analyzed using inductive content analysis. RESULTS Four themes emerged from the analysis: (1) staying engaged, (2) loss in daily life, (3) coping and adaptation, and (4) external support. Staying engaged in activities that provide a sense of usefulness or participating in leisure and recreational activities as much as possible in daily life emerged as the key theme. Retaining a sense of usefulness was considered both important and possible by having social roles or participating in functional activities. The importance of activities providing a sense of usefulness seemed to decrease over time, while the need for pleasant activities seemed to increase. Experienced loss, coping, adaptation, and available external support are important parts of the context in which the person with YOD tries to engage in daily life as much as possible. Active coping styles and external support appear to play a facilitating role in staying engaged. CONCLUSIONS It is important for people with YOD to have the opportunity to feel useful; especially in the early stages of the condition. Caregivers should be educated in ways to enhance a sense of usefulness and engagement in daily life for people with YOD.

Skill mix change between general practitioners, nurse practitioners, physician assistants and nurses in primary healthcare for older people: a qualitative study

BackgroundMore and more older adults desire to and are enabled to grow old in their own home, regardless of their physical and mental capabilities. This change, together with the growing number of older adults, increases the demand for general practitioners (GPs). However, care for older people lacks prestige among medical students and few medical students are interested in a career in care for older people. Innovative solutions are needed to reduce the demand for GPs, to guarantee quality of healthcare and to contain costs. A solution might be found in skill mix change by introducing nurse practitioners (NPs), physician assistants (PAs) or registered nurses (RNs). The aim of this study was to describe how skill mix change is organised in daily practice, what influences it and what the effects are of introducing NPs, PAs or RNs into primary healthcare for older people.MethodsIn total, 34 care providers working in primary healthcare in the Netherlands were interviewed: GPs (n = 9), NPs (n = 10), PAs (n = 5) and RNs (n = 10). Five focus groups and 14 individual interviews were conducted. Analysis consisted of open coding, creating categories and abstraction.ResultsIn most cases, healthcare for older people was only a small part of the tasks of NPs, PAs and RNs; they did not solely focus on older people. The tasks they performed and their responsibilities in healthcare for older people differed between, as well as within, professions. Although the interviewees debated the usefulness of proactive structural screening on frailty in the older population, when implemented, it was also unclear who should perform the geriatric assessment. Interviewees considered NPs, PAs and RNs an added value, and it was stated that the role of the GP changed with the introduction of NPs, PAs or RNs.ConclusionsThe roles and responsibilities of NPs, PAs and RNs for the care of older people living at home are still not established. Nonetheless, these examples show the potential of these professionals. The establishment of a clear vision on primary healthcare for older people, including the organisation of proactive healthcare, is necessary to optimise the impact of skill mix change.