Pain among nursing home patients in the Netherlands: prevalence, course, clinical correlates, recognition and analgesic treatment – an observational cohort study

BACKGROUND: Pain is highly prevalent in nursing homes (NH) in several countries. Data about pain in Dutch NH's, where medical care is delivered by specifically trained NH-physicians, are not available. The aim of the present study is to determine prevalence, course, correlates, recognition and treatment of pain among Dutch NH-patients and to make a comparison with international data. METHODS: The study-population consisted of 350 elderly NH-patients from 14 Dutch NH's. Pain (pain-subscale Nottingham Health Profile) and clinical characteristics (gender, age, cognition, depression, anxiety, sleeping problems, morbidity and functional status) were measured at baseline and at six months. Association of pain (baseline and six months) with clinical characteristics was assessed with chi-square and multiple logistic regression analyses. RESULTS: Pain-prevalence was 68.0% (40.5% mild pain symptoms, 27.5% serious pain symptoms). 80% of the patients with pain at baseline still experienced pain at six months. Serious pain at baseline was significantly associated with depression (OR: 2.56; 95% CI: 1.34-4.89) and anxiety (OR 2.47; 95% CI: 1.22-4.99). Serious pain at six months was associated with pain at baseline (OR 18.55; 95% CI: 5.19-66.31) and depression at baseline (OR: 2.63; 95% CI:1.10-6.29). Recognition of pain by NH-physicians varied (35% to 69.7%) depending on measurement instrument and severity of pain. Analgesics were received by 64.5% (paracetamol (acetaminophen), NSAIDs, opioids). Paracetamol (acetaminophen) and opioids frequently were prescribed below daily defined doses. CONCLUSION: Pain occurred frequently also among Dutch NH-patients and was associated with depression and anxiety. Recognition and treatment by NH-physicians proved sub-optimal. Future studies should focus on interventions to improve recognition and treatment of pain

Denitrification in an oligotrophic estuary: a delayed sink for riverine nitrate

Estuaries are often seen as natural filters of riverine nitrate, but knowledge of this nitrogen sink in oligotrophic systems is limited. We measured spring and summer dinitrogen production (denitrification, anammox) in muddy and non-permeable sandy sediments of an oligotrophic estuary in the northern Baltic Sea, to estimate its function in mitigating the riverine nitrate load. Both sediment types had similar denitrification rates, and no anammox was detected. In spring at high nitrate loading, denitrification was limited by likely low availability of labile organic carbon. In summer, the average denitrification rate was similar to 138 mu mol N m(-2) d(-1). The corresponding estuarine nitrogen removal for August was similar to 1.2 t, of which similar to 93% was removed by coupled nitrification-denitrification. Particulate matter in the estuary was mainly phytoplankton derived (> 70% in surface waters) and likely based on the riverine nitrate which was not removed by direct denitrification due to water column stratification. Subsequently settling particles served as a link be tween the otherwise uncoupled nitrate in surface waters and benthic nitrogen removal. We suggest that the riverine nitrate brought into the oligotrophic estuary during the spring flood is gradually, and with a time delay, removed by benthic denitrification after being temporarily ` trapped' in phytoplankton particulate matter. The oligotrophic system is not likely to face eutrophication from increasing nitrogen loading due to phosphorus limitation. In response, coupled nitrification-denitrification rates are likely to stay constant, which might increase the future export of nitrate to the open sea and decrease the estuary's function as a nitrogen sink relative to the load.Peer reviewe

Grip on challenging behaviour: a multidisciplinary care programme for managing behavioural problems in nursing home residents with dementia. Study protocol

Contains fulltext : 97945.pdf (publisher's version ) (Open Access)BACKGROUND: Behavioural problems are common in nursing home residents with dementia and they often are burdensome for both residents and nursing staff. In this study, the effectiveness and cost-effectiveness of a new care programme for managing behavioural problems will be evaluated. METHODS/DESIGN: The care programme is based on Dutch national guidelines. It will consist of four steps: detection, analysis, treatment and evaluation. A stepped wedge design will be used. A total of 14 dementia special care units will implement the care programme. The primary outcome is behavioural problems. Secondary outcomes will include quality of life, prescription rate of antipsychotics, use of physical restraints and workload and job satisfaction of nursing staff. The effect of the care programme will be estimated using multilevel linear regression analysis. An economic evaluation from a societal perspective will also be carried out. DISCUSSION: The care programme is expected to be cost-effective and effective in decreasing behavioural problems, workload of nursing staff and in increasing quality of life of residents. TRIAL REGISTRATION: The Netherlands National Trial Register (NTR). Trial number: NTR 2141

Working in group living homes for older people with dementia: the effects on job satisfaction and burnout and the role of job characteristics

ABSTRACT Background: Group living homes are a fast-growing form of nursing home care for older people with dementia. This study seeks to determine the differences in job characteristics of nursing staff in group living homes and their influence on well-being. Methods: We examined the Job Demand Control Support (JDCS) model in relation to 183 professional caregivers in group living homes and 197 professional caregivers in traditional nursing homes. Multilevel linear regression analysis was used to study the mediator effect of the three job characteristics of the JDCS-model (demands, control and social support) on job satisfaction and three components of burnout (emotional exhaustion, depersonalization and decreased personal accomplishment). Results: Demands were lower in group living homes, while control and social support from co-workers were higher in this setting. Likewise, job satisfaction was higher and burnout was lower in group living homes. Analysis of the mediator effects showed that job satisfaction was fully mediated by all three psychosocial job characteristics, as was emotional exhaustion. Depersonalization was also fully mediated, but only by control and social support. Decreased personal accomplishment was partially mediated, again only by job characteristics, control and support. Conclusion: This study indicates that working in a group living home instead of a traditional nursing home has a beneficial effect on the well-being of nursing staff, largely because of a positive difference in psychosocial job characteristic

Would we rather lose our life than lose our self? Lessons from the Dutch debate on euthanasia for patients with dementia

This article reviews the Dutch societal debate on euthanasia/assisted suicide in dementia cases, specifically Alzheimer's disease. It discusses the ethical and practical dilemmas created by euthanasia requests in advance directives and the related inconsistencies in the Dutch legal regulations regarding euthanasia/assisted suicide. After an initial focus on euthanasia in advanced dementia, the actual debate concentrates on making euthanasia/assisted suicide possible in the very early stages of dementia. A review of the few known cases of assisted suicide of people with so-called early dementia raises the question why requests for euthanasia/assisted suicide from patients in the early stage of (late onset) Alzheimer's disease are virtually non-existent. In response to this question two explanations are offered. It is concluded that, in addition to a moral discussion on the limits of anticipatory choices, there is an urgent need to develop research into the patient's perspective with regard to medical treatment and care-giving in dementia, including end-of-life care

Euthanasie bij dementie: Een reële optie?

Nursing home physicians are bound to be confronted more often with patients that have an advance directive concerning a request for euthanasia in the case of dementia. Despite the fact that in the Netherlands euthanasia in dementia, under certain conditions, is justified when a written request is present, these requests are rarely carried out.This article provides insight into the medical ethical problems that physicians may encounter when treating a patient with dementia in the posession of a written request for euthanasia. Dilemma's with respect to the patient's (in)competence, personal identity and unbearable suffering, are adressed successively. It appears that insight into the way that physicians in daily practice deal with these dilemma's is limited. More research into the issues around advance directives in dementia is recommended

Comorbidity of depression and anxiety in nursing home patients

Objectives: To assess the occurrence and risk indicators of depression, anxiety, and comorbid anxiety and depression among nursing home patients and to determine whether depression and anxiety are best described in a dimensional or in a categorical classification system. Methods: DSM and subthreshold anxiety disorders, anxiety symptoms, major and minor depression and depressive symptoms were assessed in 333 nursing home patients of somatic wards of 14 nursing homes in the north west of the Netherlands with the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and the Geriatric Depression Scale (GDS). Comorbidity was studied along a severity gradient. Logistic regression analyses were carried out to identify demographic, health-related, psychosocial and care-related correlates of anxiety and depression. Results: The prevalence of pure depression (PD) was 17.1%, of pure anxiety (PA) 4.8%, and of comorbid anxiety and depression (CAD) 5.1%. Comorbidity increased dependent on severity of both anxiety and depression. Different patterns of risk indicators were demonstrated for PA, PD and CAD for the investigated baseline characteristics. Conclusions: Comorbidity of anxiety and depression is most prevalent in the more severe depressive and anxious nursing home patients. The gradual increase of comorbidity of anxiety and depression dependent on the levels of severity of depression and anxiety suggests that for nursing home patients a dimensional classification of depression and anxiety is more appropriate than a categorical one. The observed differences in patterns of risk indicators for PA, PD and CAD support a distinguishing of anxiety and depression. Future studies are needed to assess the effect of treatment of PA, PD and CAD in nursing home patients

The effect of somatic symptom attribution on the prevalence rate of depression and anxiety among nursing home patients

The validity of diagnostic psychiatric instruments for depression and anxiety disorders may be compromised among patients with complex physical illness and disability. The objective of this study was to determine the effect on the prevalence rate of depression and anxiety in a nursing home Population of attributing somatic symptoms of depression and anxiety to either somatic or psychiatric disorder. Symptoms of major depression (MD), generalized anxiety disorder (GAD) and panic disorder (PD) were measured using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Somatic symptoms of MD, GAD and PD were attributed to somatic causes when the interviewer was not sure about a psychiatric cause. To analyse the effect of this attribution on the prevalence rate of MD, GAD and PD, a sensitivity analysis was undertaken in which symptoms that were attributed to somatic causes were recoded as symptoms attributed to psychiatric disorder. Prevalence rates of MD, GAD and PD were calculated before and after recoding. The prevalence of MD after recoding rose from 7.5% to 8.1%. The prevalence of GAD did not change. The prevalence of PD rose from 1.5% to 1.8%. Attribution of somatic symptoms to either somatic or psychiatric disorder when the interviewer was not sure about a psychiatric cause of the somatic symptoms had only a very modest effect on the prevalence rate of major depression, generalized anxiety disorder and panic disorder in a nursing home population