N. Van Den Noortgate

A home-based multidimensional exercise program reduced physical impairment and fear of falling.

Abstract Objective. To investigate the efficacy of a guided and graded home-based exercise program for improving a range of physical outcomes in older people. Design. Controlled clinical trial of 16 weeks Setting. Two geographical areas in Gent, Belgium Participants. 66 independent-living older people (age: 71-98) with a history of falls and moderate physical impairment Intervention. Twenty-four 30-minute training sessions were given by a trained physiotherapist over a period of 16 weeks in the participant’s home. Different types of exercises on balance, aerobic performance, flexibility, and muscle strength were provided. Main outcome measures. Muscle strength, static and dynamic balance, aerobic performance, activities in daily living, fear of falling and avoidance of daily activities were assessed at baseline and after 16 weeks intervention. Results: At baseline, there were no significant differences in the measured variables between exercise and control groups. After 16 weeks, the exercise group showed significantly improved ankle muscle strength, balance performance and aerobic capacity, and decreased fear of falling, dependency in daily activities and avoidance of daily activities compared to the control group. The improvements in knee muscle strength, timed chair stands, and functional reach were not significant. Conclusion: The home-based, individualized exercise program was effective in reducing several physical factors associated with falls in community-dwelling older people with moderate physical impairment. The decrease in fear of falling and other behavioural variables needs to be considered with care and needs further investigation.

DO-NOT-RESUSCITATE DECISIONS IN A LARGE TERTIARY HOSPITAL: DIFFERENCES BETWEEN WARDS AND RESULTS OF A HOSPITAL-WIDE INTERVENTION

Abstract Background: Despite the advent of palliative care, the quality of dying in the hospital remains poor. Differences in quality of end-of-life practice between hospital wards are well known in clinical practice but rarely have been investigated. Methods: A prospective observation of do-not-resuscitate (DNR) decisions was conducted in patients dying in a Belgian university hospital before (115 patients) and after (113 patients) a hospital-wide intervention consisting in informing hospital staff on the law on Patient’s Rights and the introduction of a new DNR form. The new DNR form puts more emphasis on the motivation of the DNR decision and on the description of the participants in the decision-making process. Results: The completion of DNR forms improved after the intervention: physicians better documented who participated in DNR decisions (for participation of family: 63% after the intervention vs. 44% before the intervention, p = 0.022, for nurses: 27% vs. 14%, p = 0.047) and the motivation for these decisions (59% vs. 32%, p = 0.001). However, there was no difference in referral to the intensive care unit (ICU) at the end of life (in 40% of patients after and 37% before the intervention). Furthermore, the number of patients dying without DNR form on the wards was similar (13% and 8%). Surgical patients and patients with non-malignant diseases were more often referred to ICU at the end of life (71% in surgical vs. 35% in medical patients, p < 0.001 and 49% in patients with non-malignant diseases vs. 23% in patients with malignancy, p < 0.001). Moreover, surgical patients less frequently received a DNR order (56% in surgical vs. 92% in medical patients, p = 0.007). Conclusions: The introduction of a new DNR form and informing hospital staff on patients) right to information did not improve physicians) end-of-life practice. Transition from life-prolonging treatment to a more palliative approach was less anticipated in surgical patients and patients with non-malignant diseases.

European palliative care guidelines: how well do they meet the needs of people with impaired cognition?

Objective Numbers of people dying with cognitive impairment (intellectual disability (ID), dementia or delirium) are increasing. We aimed to examine a range of European national palliative care guidelines to determine if, and how well, pain detection and management for people dying with impaired cognition are covered. Methods Questionnaires were sent to 14 country representatives of the European Pain and Impaired Cognition (PAIC) network who identified key national palliative care guidelines. Data was collected on guideline content: inclusion of advice on pain management, whether cognitively impaired populations were mentioned, assessment tools and management strategies recommended. Quality of guideline development was assessed with the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. Results 11 countries identified palliative care guidelines, 10 of which mentioned pain management in general. Of these, seven mentioned cognitive impairment (3 dementia, 2 ID and 4 delirium). Half of guidelines recommended the use of pain tools for people with cognitive impairment; recommended tools were not all validated for the target populations. Guidelines from the UK, the Netherlands and Finland included most information on pain management and detection in impaired cognition. Guidelines from Iceland, Norway and Spain scored most highly on AGREE rating in terms of developmental quality. Conclusions European national palliative care guidelines may not meet the needs of the growing population of people dying with cognitive impairment. New guidelines should consider suggesting the use of observational pain tools for people with cognitive impairment. Better recognition of their needs in palliative care guidelines may drive improvements in care.

A qualitative exploration of the collaborative working between palliative care and geriatric medicine: Barriers and facilitators from a European perspective.

BackgroundWith an increasing number of people dying in old age, collaboration between palliative care and geriatric medicine is increasingly being advocated in order to promote better health and health care for the increasing number of older people. The aim of this study is to identify barriers and facilitators and good practice examples of collaboration and integration between palliative care and geriatric medicine from a European perspective.MethodsFour semi-structured group interviews were undertaken with 32 participants from 18 countries worldwide. Participants were both clinicians (geriatricians, GPs, palliative care specialists) and academic researchers. The interviews were transcribed and independent analyses performed by two researchers who then reached consensus.ResultsLimited knowledge and understanding of what the other discipline offers, a lack of common practice and a lack of communication between disciplines and settings were considered as barriers for collaboration between palliative care and geriatric medicine. Multidisciplinary team working, integration, strong leadership and recognition of both disciplines as specialties were considered as facilitators of collaborative working. Whilst there are instances of close clinical working between disciplines, examples of strategic collaboration in education and policy were more limited.ConclusionsImproving knowledge about its principles and acquainting basic palliative care skills appears mandatory for geriatricians and other health care professionals. In addition, establishing more academic chairs is seen as a priority in order to develop more education and development at the intersection of palliative care and geriatric medicine.

Kidney in old age.

Abstract Epidemiological studies have shown that chronic kidney disease (CKD) is a major health problem especially in an older population. Given the growing segment of the elderly population and the important implication of renal disease on health care, this review discusses the structural and functional changes of the ageing kidney and the underlying mechanisms of age-dependent injury. The implications of these changes in daily clinical practice and the management of CKD is also briefly overviewed.

THE IMPORTANCE OF A GERIATRIC APPROACH IN MEDICINE

Due to healthier lifestyles and improved medical and hygienic care, Europeans are living increasingly longer. Overall, life expectancy has risen in the last 40 years, by over 8 years for men (from 67.3 years to 75.6 years today) and for women over the same period by nearly 9 years (from 73 years to 81.8 years today). Another increase of 6 years for men and 5 years for women is projected by the year 2050. This development has implications for the number of the very old (over 80 years). Their share of the total population will nearly triple by the year 2050, from 4.1 percent today to 11.4 percent. This will massively alter the generational structure. The average age (median age) in Europe will rise from 39 years today to 49 years. As a consequence of this evolution, the absolute number of frail older persons will increase too (1). Rapid ageing of the society increases the demand for specialists in the health care of older people in order to ensure both clinical and research excellence. A BRIEF HISTORY OF GERIATRICS IN EUROPE AND IN BELGIUM

Streptococcus milleri sepsis with lung and brain abscesses

Abstract Streptococcus milleri sepsis with lung and brain abscesses. A 69-year old man developed a clinical picture in two phases. A Streptococcus milleri sepsis with metastatic endophtalmitis was treated during 3 weeks with conventional doses amoxycillin/clavulanate with apparently positive clinical evolution. Shortly afterwards he developed a second episode of sepsis with, documented on CT-scan, multiple lung abscesses and a solitary brain abscess. Cultures of the brain abscess were also positive for S. milleri. In the end a slow but complete recovery was seen under high doses penicillin and clindamycin IV. The different species of the Streptococcus milleri group (SMG) are part of the normal flora of the mouth, the vagina, the respiratory and the gastrointestinal tract. In the vast majority of cases SMG bacteremia is preceded by local trauma to the mucosal barrier. Although these bacteremic episodes are often transient, metastatic purulent lesions, especially in the abdominal and thoracic cavities, may complicate them. Multiple positive blood cultures or polymicrobial bacteremia strongly suggest a suppurative focus of infection and should prompt clinicians to initiate further thorough investigations. Cornerstones of effective treatment are intravenous antimicrobial therapy and surgical drainage in case of abcedation. Since SMG largely remain susceptible, penicillin stays the treatment of choice. Yet, the frequent polymicrobial nature of these infections often necessitates initial broad-spectrum antimicrobial coverage.

Increasing use of cognitive measures in the operational definition of frailty—A systematic review

Ageing is associated both with frailty and cognitive decline. The quest for a unifying approach has led to a new concept: cognitive frailty. This systematic review explores the contribution of cognitive assessment in frailty operationalization. PubMed, Web of Knowledge and PsycINFO were searched until December 2016 using the keywords aged; frail elderly; aged, 80 and over; frailty; diagnosis; risk assessment and classification, yielding 2863 hits. Seventy-nine articles were included, describing 94 frailty instruments. Two instruments were not sufficiently specified and excluded. 46% of the identified frailty instruments included cognition. Of these, 85% were published after 2010, with a significant difference for publication date (X2 = 8.45, p < .05), indicating increasing awareness of the contribution of cognitive deficits to functional decline. This review identified 7 methods of cognitive assessment: dementia as co-morbidity; objective cognitive-screening instruments; self-reported; specific signs and symptoms; delirium/clouding of consciousness; non-specific cognitive terms and mixed assessments. Although cognitive assessment has been increasingly integrated in recently published frailty instruments, this has been heterogeneously operationalized. Once the domains most strongly linked to functional decline will have been identified and operationalized, this will be the groundwork for the identification of reversible components, and for the development of preventive interventional strategies.

The Belgian geriatric day hospitals as part of a care program for the geriatric patient: first results of the implementation at the national level.

Abstract Purpose: In order to deliver individual, specialized and multidisciplinary care for older people, the Belgian national health authorities developed the care program for the geriatric patient. In that context, 48 geriatric day hospitals (GDHs) have been financed by the government since January 1st 2006. The main objective of this study is to describe the patient characteristics, facility features and activities related to the Belgian GDHs. Methods: A prospective, multicenter study was performed from October 1st till December 31st 2006 in all 48 GDHs. For each GDH a transversal data collection was carried out. In the same period all patients scheduled for the GDHs were registered and followed for 3 months. Therefore two questionnaires were developed using Filemaker® software: one for each GDH and one for each patient . There were no exclusion criteria. Results: Six GDHs did not complete one or both questionnaires. Consequently, the results of 42 GDHs were included. GDHs with more years of activity had significantly more new patient contacts per day. Activities in the Belgian GDHs were mainly diagnostic with emphasis on geriatric syndromes and specific medical problems. The reason for admission to the GDH was often multifactorial. The syndromes that motivated patients 75 or older to visit the GDH were clearly geriatric (mainly cognitive disorders) and represent the principle public health problems in this age category. Despite the legal provision preserving GDHs for patients 75 years or older a quarter of all patients was younger than 75, presenting with a geriatric syndrome. The contribution of the general practitioners was limited. Conclusions: Activities in the Belgian GDHs are mainly diagnostic with emphasis on geriatric syndromes (particularly cognitive disorders) and specific medical problems. More information is needed on the knowledge and expectations of general practitioners in order to establish a closer collaboration.

Balancing truth-telling: relatives acting as translators for older adult cancer patients of Turkish or northwest African origin in Belgium.

&NA; The first generation of Turkish and Northwest African immigrants in Belgium are ageing and at risk for developing cancer. Relatives play an important role and provide both emotional and practical care, including mental support and acting as a contact person and/or a translator for improving access to healthcare, as most patients and their spouses have only a limited command of the language. Although access to professional interpreters has shown to be the best guarantee for qualitative healthcare, oncology health providers working with relatives as interpreters is much more common than professional interpreters. The aim of this study was to provide insight into the process wherein relatives balance truth‐telling in translating for an older family member diagnosed with cancer. This was a qualitative research study, with elements of constructivist grounded theory. Twenty‐eight loosely structured interviews were conducted. Most relatives consider it their responsibility to contribute to a positive attitude of the patient. Relatives decided to what extent they inform the patient, based on several motives and embedded in their assessment of the patients emotional strength, understanding and need to be informed. What they decide influences the way they act as a translator and/or a contact person between the patient and health professional(s). Some considered it best to omit medical information while others considered it best to inform the patient fully. The results emphasise the importance for healthcare providers to take into account the complexity and unpredictable character of the process of balancing truth‐telling when family members translate for their ill older relative.