De effectiviteit van valklinieken in Nederland

Recent zijn er twee artikelen gepubliceerd, waarbij er gekeken is naar de effectiviteit van een multifactorieel valpreventieprogramma uitgevoerd door valklinieken in Nederland. Beide artikelen laten negatieve resultaten zien. Het is echter de vraag of deze twee studies representatief zijn voor de situatie zoals het er in de meeste valklinieken in Nederland aan toegaat. Twee belangrijke verschillen zitten in de patiëntenselectie en de uitvoer van het valpreventieprogramma. Op een valkliniek is het belangrijk die patiënten te selecteren met het hoogste valrisico (≥ 2 valincidenten/ jaar en/of ≥ 4 valrisicofactoren) en om een actieve, directe aanpak van het valprobleem na te streven om de effectiviteit van de valkliniek te optimaliseren

Valpreventie bij de oudere patiënt

Falls may lead to functional impairment, fear of falling, decreased quality of life, high health care costs and mortality. A case of an older adult presented in this article, illustrates the multifactorial nature of risk of falling and fall prevention strategies. Recently, meta-analyses were performed to determine the effectiveness of interventions to prevent falls and to explore the effect of intervention components in reducing fear of falling. The single interventions whole body vibration, exercise and quality improvement strategies are associated with a reduction in number of fallers. Common components of multiple interventions significantly associated with a reduction in number of fallers are exercise, assistive technology, environmental modifications, quality improvement strategies and basic falls risk assessment. Interventions with meditation, holistic exercises or body awareness are more effective in reducing fear of falling than interventions without these components. The patient's risk evaluation and personal preferences should be taken into account when developing a treatment plan

Contextual determinants influencing the implementation of fall prevention in the community: a scoping review

Background: Successful implementation of multifactorial fall prevention interventions (FPIs) is essential to reduce increasing fall rates in communitydwelling older adults. However, implementation often fails due to the complex context of the community involving multiple stakeholders within and across settings, sectors, and organizations. As there is a need for a better understanding of the occurring context-related challenges, the current scoping review purposes to identify what contextual determinants (i.e., barriers and facilitators) influence the implementation of FPIs in the community. Methods: A scoping reviewwas performed using the Arksey andO’Malley framework. First, electronic databases (Pubmed, CINAHL, SPORTDiscus, PsycINFO) were searched. Studies that identified contextual determinants that influence the implementation of FPIs in the community were included. Second, to both validate the findings from the literature and identify complementary determinants, health and social care professionals were consulted during consensus meetings (CMs) in four districts in the region of Utrecht, the Netherlands. Data were analyzed following a directed qualitative content analysis approach, according to the 39 constructs of the Consolidated Framework for Implementation Research. Results: Fourteen relevant studies were included and 35 health and social care professionals (such as general practitioners, practice nurses, and physical therapists) were consulted during four CMs. Directed qualitative content analysis of the included studies yielded determinants within 35 unique constructs operating as barriers and/or facilitators. The majority of the constructs (n = 21) were identified in both the studies and CMs, such as “networks and communications”, “formally appointed internal implementation leaders”, “available resources” and “patient needs and resources”. The other constructs (n = 14) were identified only in the . Discussion: Findings in this review show that awide array of contextual determinants are essential in achieving successful implementation of FPIs in the community. However, some determinants are considered important to address, regardless of the context where the implementation occurs. Such as accounting for time constraints and financial limitations, and considering the needs of older adults. Also, broad cross-sector collaboration and coordination are required in multifactorial FPIs. Additional context analysis is always an essential part of implementation efforts, as contexts may differ greatly, requiring a locally tailored approach

Validity of a screening method for delirium risk in older patients admitted to a general hospital in the Netherlands

Objective: Delirium is an impactful, frequently occurring complication in older hospital patients. Consequently, risk stratification of delirium was included in a set of mandatory safety measures in general hospitals in the Netherlands. This risk stratification contains three consensus-based questions that have not been validated. Therefore, we evaluated their predictive performance and examined whether other routinely collected patient data can improve the prediction of delirium. Method: Using data from a continuous data registry from a general hospital, the prediction of the three questions was compared with the occurrence of delirium in 3786 older patients. Regression models were fitted that included other patient-related delirium risk factors. The performance was expressed by discrimination and calibration. Results: Delirium occurrence was 16.8%. The three questions, a regression model with the three questions, a full model and a reduced model – including the three questions, age, use of glasses, number of medications and Katz-ADL – showed sensitivities of 0.88, 0.88, 0.92 and 0.91 and specificities of 0.52, 0.52, 0.53 and 0.54, when treated as dichotomous models respectively. The three risk models had C-statistics of 0.81, 0.86 and 0.86, with excellent p-values of the U-statistics. Conclusion: The three risk-stratification questions show promising results but substantial overprediction (49% predicting positive). Further validation should be done outside the Netherlands, given the potential bias as a result of clinical activities following the risk stratification. The reduced model shows excellent calibration performance, indicating good prediction in each individual patient. In clinical practice, this advantage adds to clinical reasoning

Accidental falling in community-dwelling elderly with chronic kidney disease

Purpose: The aim of the current study was to evaluate the association between a decreased estimated glomerular filtration rate (eGFR) and accidental falling in elderly patients who visited the day clinic of the department of geriatric medicine of the University of Medical Center Utrecht (UMCU). Study design: A cross-sectional analysis with people aged ≥ 65 years of the Utrecht Cardiovascular Cohort was performed. Patients were stratified into different stages of kidney disease (< 45, 45–59, and ≥ 60 ml/min per 1.73 m2). Logistic regression models were used to evaluate the association between chronic kidney disease and falling. Results: Our analysis included 1000 participants with a mean age 79.4 (± 6.6) years, of whom 38% had an eGFR of < 60 ml/min per 1.73 m2 and 17% < 45 ml/min per 1.73 m2. Univariate analysis showed a significant higher prevalence [odds ratio 1.75 (95% confidence interval 1.21–2.53; p ≤ 0.01)] of falling in the population with an eGFR < 45 ml/min per 1.73 m2 compared to patients with an eGFR ≥ 60 ml/min per 1.73 m2. After correcting for multiple potential confounders in the multivariate analysis, this association was no longer present. Conclusions: In geriatric patients ≥ 65 years, patients with a decreased eGFR fall more often than patients with a preserved kidney function. This seems to be related with the risk profile of patients with CKD and not with a decreased eGFR itself, as after correcting for potential confounders no association remained. Nevertheless, accidental falling is a highly prevalent problem in the elderly CKD population. Therefore, nephrologists should actively ask about accidental falling, and thereby screen for high-risk patients

Accidental falling in community-dwelling elderly with chronic kidney disease

Purpose: The aim of the current study was to evaluate the association between a decreased estimated glomerular filtration rate (eGFR) and accidental falling in elderly patients who visited the day clinic of the department of geriatric medicine of the University of Medical Center Utrecht (UMCU). Study design: A cross-sectional analysis with people aged ≥ 65 years of the Utrecht Cardiovascular Cohort was performed. Patients were stratified into different stages of kidney disease (< 45, 45–59, and ≥ 60 ml/min per 1.73 m2). Logistic regression models were used to evaluate the association between chronic kidney disease and falling. Results: Our analysis included 1000 participants with a mean age 79.4 (± 6.6) years, of whom 38% had an eGFR of < 60 ml/min per 1.73 m2 and 17% < 45 ml/min per 1.73 m2. Univariate analysis showed a significant higher prevalence [odds ratio 1.75 (95% confidence interval 1.21–2.53; p ≤ 0.01)] of falling in the population with an eGFR < 45 ml/min per 1.73 m2 compared to patients with an eGFR ≥ 60 ml/min per 1.73 m2. After correcting for multiple potential confounders in the multivariate analysis, this association was no longer present. Conclusions: In geriatric patients ≥ 65 years, patients with a decreased eGFR fall more often than patients with a preserved kidney function. This seems to be related with the risk profile of patients with CKD and not with a decreased eGFR itself, as after correcting for potential confounders no association remained. Nevertheless, accidental falling is a highly prevalent problem in the elderly CKD population. Therefore, nephrologists should actively ask about accidental falling, and thereby screen for high-risk patients

Predictive value of each geriatric assessment domain for older patients with cancer : A systematic review

BACKGROUND: A geriatric assessment (GA) is increasingly used to help guide treatment decisions in older patients with cancer. However, there is no consensus regarding which domains should be included in the GA. In addition, the field of geriatric oncology moves very fast and as a result many new studies have been published since the last review in 2015. Therefore, the objective of this systematic review is to evaluate which domains of the GA could predict patient-related treatment outcomes of older patients with cancer and thereby should be included in a GA. METHODS: A systematic literature search was performed for publications in English or Dutch between September 2006 and July 2017 addressing the association between individual domains of the GA and mortality, postoperative complications, or systemic treatment-related outcomes in older patients with cancer. RESULTS: Eight different domains were evaluated in 46 publications, namely functional status, nutritional status, cognition, mood, physical function, fatigue, social support, and falls. All eight domains were predictive for at least one of the investigated outcomes but the results were quite variable across studies. Physical function and nutritional status were the domains most often associated with mortality and systemic treatment-related outcomes, and the domain physical function was most often associated with postoperative complications. CONCLUSION: Overall, this review demonstrates that the GA should minimally consist of physical function and nutritional status, when the aim is to predict patients-related outcomes of older patients with cancer, although the results are quite heterogeneous. For the other domains, the findings are too inconsistent to draw conclusions about their overall predictive ability

Incidence, Predictive Factors, and Effect of Delirium after Transcatheter Aortic Valve Replacement

OBJECTIVES The purpose of this study was to investigate the incidence, predictive factors, and effect of postoperative delirium (POD) among patients treated by transcatheter aortic valve replacement (TAVR). BACKGROUND Patients undergoing operations that involve valve replacement appear at higher risk of POD than patients subjected to coronary artery bypass surgery alone. In patients with severe aortic stenosis undergoing TAVR, little is known regarding the potential impact of POD on the clinical outcomes. METHODS A retrospective observational cohort study of 268 consecutive patients who underwent TAVR at our institute was conducted. Delirium was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorder, 4th Edition criteria. The primary outcome of this study was the presence of in-hospital POD after TAVR. RESULTS The incidence of POD after TAVR was 13.4% (n = 36). Of these cases, 18 were associated with post-procedural complications, including major vascular complications/bleeding (n = 4), stroke (n = 3), acute kidney injury (n = 3), atrial fibrillation (n = 4), and infectious disease (n = 4). POD was most frequently diagnosed on the second day after TAVR (interquartile range [IQR]: 1 to 5 days) and was associated with prolonged in-hospital stay regardless of complications (in uncomplicated TAVR: 6 days [IQR: 5 to 10 days] vs. 5 days [IQR: 4 to 5 days]; p <0.001; and in complicated TAVR: 9 days [IQR: 8 to 15 days] vs. 6 days [IQR: 5 to 9 days]; p<0.001). Predictors of POD were nontransfemoral (transapical/transaortic) access (odds ratio [OR]: 7.74; 95% confidence interval [CI]: 3.26 to 18.1), current smoking (OR: 3.99; 95% CI: 1.25 to 12.8), carotid artery disease (OR: 3.88; 95% CI: 1.50 to 10.1), atrial fibrillation (OR: 2.74; 95% CI: 1.17 to 6.37), and age (OR: 1.08; 95% CI: 1.00 to 1.17, per year increase). After a median follow-up of 16 months (IQR: 6 to 27 months), POD remained an independent predictor of mortality in patients undergoing transfemoral TAVR compared with the nontransfemoral TAVR (hazard ratio: 2.81; 95% CI: 1.16 to 6.83 vs. hazard ratio: 0.43; 95% Cl: 0.10 to 1.76), adjusted for possible confounders in a time-dependent Cox-regression model (i. e., age, sex, Logistic EuroSCORE and the occurrence of complications). CONCLUSIONS POD after TAVR has an incidence of around 13% and occurs early in the post-operative course. Nontransfemoralaccess is strongly associated with the occurrence of POD. Patients who develop POD show prolonged in-hospital stay and impaired long-term survival. (J Am Coll Cardiol Intv 2016; 9: 160-8) (C) 2016 by the American College of Cardiology Foundation

The effect of providing prescribing recommendations on appropriate prescribing : A cluster-randomized controlled trial in older adults in a preoperative setting

Aims: The Systematic Tool to Reduce Inappropriate Prescribing is a method to assess patient's medication and has been incorporated into a clinical decision support system: STRIP Assistant. Our aim was to evaluate the effect of recommendations generated using STRIP Assistant on appropriate prescribing and mortality in a preoperative setting. Methods: This cluster-randomized controlled trial was carried out at the preoperative geriatric outpatient clinic. Residents who performed a comprehensive geriatric assessment were randomized to the control group and intervention group in a 1:1 ratio. Visiting patients aged 70 years or older on 5 or more medications were included. Intervention: prescribing recommendations were generated by a physician using STRIP Assistant and given to the resident. Control group residents performed a medication review according to usual care. Primary outcome: number of medication changes made because of potential prescribing omissions (PPOs), potentially inappropriate medications (PIMs), and suboptimal dosages according to the prescribing recommendations. Secondary outcome: 3-month postoperative mortality. Results: 65 intervention and 59 control patients were included, attended by 34 residents. Significantly more medication changes because of PPOs and PIMs were made in the intervention group than in the control group (PPOs 26.2% vs 3.4%, odds ratio 0.04 [95% confidence interval 0.003–0.46] P <.05; PIMS 46.2% vs 15.3% odds ratio 0.14 [95% confidence interval 0.07–0.57] P <.005). There were no differences in dose adjustments or in postoperative mortality. Conclusion: Prescribing recommendations generated with the help of STRIP Assistant improved appropriate prescribing in a preoperative geriatric outpatient clinic but did not affect postoperative mortality