Advance Care Planning In Frail Older People In The Netherlands

Advance Care Planning (ACP) enables individuals to define goals and preferences for future medical treatment and care, to discuss these goals and preferences with family and healthcare providers, and to record and review these preferences if appropriate. ACP may be especially relevant for frail older people since this population is most likely to develop physical and cognitive deficits in the near future and most likely to have to rely on others to communicate their treatment preferences. This thesis describes the effects of an ACP program in a randomized controlled trial among frail older people in the Netherlands, and concludes with recommendations for clinical practice and future research

Pam Kaspers. End-of-life care and preferences for (non) treatment decisions in older people during the last 3 months of life

Review: Pam Kaspers beschrijft in haar proefschrift de resultaten van een onderzoek naar wensen rondom levenseindezorg en beslissingen omtrent het wel of niet ondergaan van medische behandelingen van ouderen. Bijzondere aandacht wordt besteed aan de rol van wilsverklaringen. Zij heeft voor haar onderzoek voornamelijk gebruik gemaakt van gegevens over overleden leden van het LASAouderencohort (Longitudinal Aging Study Amsterdam) en van een cohort van ouderen met een wilsverklaring. De resultaten van het onderzoek zijn beschreven in vijf hoofdstukken

Corruption in the Middle East and the Limits of Conventional Approaches

Die Unzufriedenheit mit der verbreiteten Korruption war 2011/2012 eine wesentliche Ursache für die arabischen Unruhen und weitere Aufstände weltweit. Der Fall Jordanien zeigt allerdings, dass konventionelle Ansätze zur Bekämpfung von Korruption nicht ausreichen. Eine angemessene Strategie gegen Korruption muss diese als ein Problem der Verteilungsgerechtigkeit und nicht des Strafrechts verstehen. Wie in allen anderen arabischen Staaten ist die Unzufriedenheit in der Bevölkerung über die offensichtliche Korruption auch in Jordanien beträchtlich. Allerdings wird im Allgemeinen nicht über Fälle von Bestechung und Erpressung geklagt, die weniger häufig vorkommen, sondern über lokale Praktiken politischer Patronage und Begünstigung, die unter dem Begriff "Wasta" zusammengefasst werden. "Wasta" wurde bislang als Form der Korruption und strafrechtliches Problem angesehen, weshalb Versuche zur Eindämmung überwiegend ineffizient blieben: "Wasta"-Praktiken werden in der Regel nicht mit Rechtsverstößen verbunden, sondern bewegen sich innerhalb formal legaler Verfahren. Konventionelle Ansätze zur Bekämpfung von Korruption, die sich an rechtsstaatlichen Grundsätzen und Transparenz orientieren, sind deshalb nicht zielführend. Demokratisierung allein ist ebenfalls ungeeignet, das Problem „Wasta” zu lösen. In der parlamentarischen Praxis macht "Wasta" den Großteil der Aktivitäten aller Parlamentsmitglieder aus. Diese werden deshalb als persönliche Dienstleister für ihre Wahlbezirke und nicht als Mitglieder einer gesetzgebenden Körperschaft wahrgenommen. Gleichzeitig hält die Bevölkerung das Parlament für eine zutiefst korrupte Institution. "Wasta" wird problematisch, wenn diese Praxis zu einem ungleichen Zugang der Bürger zu öffentlichen Ressourcen führt. Statt sich nur auf politische und administrative Reformen zu konzentrieren, muss der Fokus der Bekämpfung auf den (Wieder-)Aufbau wohlfahrtsstaatlicher Strukturen gelegt werden, zu denen alle Bürger gleichermaßen Zugang haben

Advance Care Planning for frail older adults: Findings on costs in a cluster randomised controlled trial

Background: Advance Care Planning aims at improving alignment of care with patients’ preferences. This may affect costs of medical care. Aim: To determine the costs of an Advance Care Planning programme and its effects on the costs of medical care and on concordance of care with patients’ preferences. Design/settings/participants: In a cluster randomised trial, 16 residential care homes were randomly allocated to the intervention group, where frail, older participants were offered facilitated Advance Care Planning conversations or to the control group. We calculated variable costs of Advance Care Planning per participant including personnel and travel costs of facilitators. Furthermore, we assessed participants’ healthcare use during 12 months applying a broad perspective (including medical care, inpatient days in residential care homes, home care) and calculated costs of care per participant. Finally, we investigated whether treatment goals were in accordance with preferences. Analyses were conducted for 97 participants per group. Trial registration number: NTR4454. Results: Average variable Advance Care Planning costs were €76 per participant. The average costs of medical care were not significantly different between the intervention and control group (€2360 vs €2235, respectively, p = 0.36). Costs of inpatient days in residential care homes (€41,

A cluster randomized controlled trial on the effects and costs of advance care planning in elderly care: Study protocol

Background: Currently, health care and medical decision-making at the end of life for older people are often insufficiently patient-centred. In this trial we study the effects of Advance Care Planning (ACP), a formalised process of timely communication about care preferences at the end of life, for frail older people. Methods/Design: We will conduct a cluster randomised controlled trial among older people residing in care homes or receiving home care in the Netherlands. The intervention group will receive the ACP program Respecting Choices® in addition to usual care. The control group will receive usual care only. Participants in both groups will fill out questionnaires at baseline and after 12 months. We hypothesize that ACP will lead to better patient activation in medical decision making and quality of life, while reducing the number of medical interventions and thus health care costs. Multivariate analysis will be used to compare differences between the intervention group and the control group at baseline and to compare differences in changes after 12 months following the inclusion. Discussion: Our study can contribute to more understanding of the effects of ACP on patient activation and quality of life in frail older people. Further, we will gain insight in the costs and cost-effectiveness of ACP. This study will facilitate ACP policy for older people in the Netherlands. Trial registration: Nederlands Trial Register: NTR4454

Plasma lipid profiles discriminate bacterial from viral infection in febrile children

Fever is the most common reason that children present to Emergency Departments. Clinical signs and symptoms suggestive of bacterial infection are often non-specific, and there is no definitive test for the accurate diagnosis of infection. The 'omics' approaches to identifying biomarkers from the host-response to bacterial infection are promising. In this study, lipidomic analysis was carried out with plasma samples obtained from febrile children with confirmed bacterial infection (n = 20) and confirmed viral infection (n = 20). We show for the first time that bacterial and viral infection produces distinct profile in the host lipidome. Some species of glycerophosphoinositol, sphingomyelin, lysophosphatidylcholine and cholesterol sulfate were higher in the confirmed virus infected group, while some species of fatty acids, glycerophosphocholine, glycerophosphoserine, lactosylceramide and bilirubin were lower in the confirmed virus infected group when compared with confirmed bacterial infected group. A combination of three lipids achieved an area under the receiver operating characteristic (ROC) curve of 0.911 (95% CI 0.81 to 0.98). This pilot study demonstrates the potential of metabolic biomarkers to assist clinicians in distinguishing bacterial from viral infection in febrile children, to facilitate effective clinical management and to the limit inappropriate use of antibiotics

Assessment of verbal and visuospatial working memory in mild cognitive impairment and Alzheimer's dementia

In addition to episodic memory impairment, working memory may also be compromised in mild cognitive impairment (MCI) or Alzheimer's dementia (AD), but standard verbal and visuospatial span tasks do not always detect impairments.Objective:To examine whether more complex verbal and visuospatial working memory tasks result in more reliable impairment detection.Methods:The Digit Span (forward, backward and sequencing), Spatial Span (forward and backward) and Spatial Addition test from the Wechsler batteries were administered to MCI and AD patients and performance compared to healthy older adult controls.Results:Results showed that both the MCI and AD patients had impaired performance on the Spatial Addition test. Both groups also had impaired performance on all three Digit Span conditions, but no differences were found between forward and backward conditions in any of the groups. The sequencing condition differed from the backward condition only in the AD group. Spatial Span performance was impaired in AD group patients but not in MCI patients.Conclusion:Working memory deficits are evident in MCI and AD even on standard neuropsychological tests. However, available tests may not detect subtle impairments, especially in MCI. Novel paradigms tapping the episodic buffer component of working memory may be useful in the assessment of working memory deficits, but such instruments are not yet available for clinical assessment