Search

Objectives: Cognitive impairment, pain and depressive symptoms are common and interrelated factors in older adults. However, the directionality and specificity of their association remains unclarified. This study explored whether these factors prospectively increase reciprocal risk and examined the longitudinal association between these factors and quality of life (QoL). Methods: This study used longitudinal data from The Older Persons and Informal Caregivers Survey Minimal Data Set (TOPICS‐MDS; the Netherlands). Older adults self‐reported cognitive impairment, pain, depressive symptoms and QoL at baseline and after 6 and 12 months of follow‐up. The Random Intercept Cross‐Lagged Panel Model was used to assess the prospective association between the three factors, while a multilevel linear regression analysis in a two‐level random intercept model was used to examine the longitudinal associations between the three factors and QoL at the within‐person level. Results: The data of 11,582 home‐dwelling older adults with or without subjective cognitive impairment were analysed. At the within‐person level, pain at 6 months was associated with subsequent depressive symptoms (β = 0.04, p = 0.024). The reverse association from depression to pain, and longitudinal associations between pain and subjective cognitive impairment and between depressive symptoms and subjective cognitive impairment were non‐significant. Pain, depressive symptoms and subjective cognitive impairment showed a significant association with poor QoL 6 months later. Conclusions: A directional relationship was observed from pain to depressive symptoms. Pain reduction holds a potential benefit in the prevention of depressive symptoms, ultimately optimising the QoL of older adults. Key points: Older adults have multiple chronic conditions, and subjective cognitive impairment, pain and depressive symptoms are common and interrelated factors which affect the quality of life.Home‐dwelling older adults experiencing pain were more likely to report later depressive symptoms.Pain, depressive symptoms and subjective cognitive impairment were associated with subsequent poor quality of life.Pain reduction may help prevent depressive symptoms and poor quality of life. [ABSTRACT FROM AUTHOR]

Objectives: For older people who worry about their memory, their general practitioner (GP) is often the first healthcare professional they turn to. This study aims to increase knowledge of GPs' daily practice on diagnostic strategies for patients who present themselves with memory complaints and/or worries about dementia for the first time in general practice and to explore associations of patients' characteristics with these strategies. Method: Retrospective observational study using electronic patient records from patients presenting with memory complaints between 2012 and 2019. The patient records are derived from a Dutch primary care registration network. The decision on diagnostic strategy was extracted and categorized as (1) wait and see, (2) diagnostic testing in primary care, or (3) referral. Patient characteristics (gender, age, general practice, level of comorbidities, chronic polypharmacy, and the number of consultations on memory complaints), fear of developing dementia, and information on why the first consultation on memory complaints was scheduled were extracted. Results: A total of 228 patients were included. Most patients were cared for within primary care, either for further primary care diagnostics (56.1%) or because a wait‐and‐see strategy was pursued (14.9%). One‐third (28.9%) of patients were referred. Differences between diagnostic strategies in patient characteristics, fear of developing dementia, or reason for first consultation between these diagnostic strategies were not found, nor were these variables predictive of referral. Conclusion: Most Dutch patients with memory complaints and/or worries about dementia who seek help from their GP for the first time are cared for in the primary care setting for the following 6 months. The lack of association between included patient characteristics and diagnostic strategies highlights the complexity of the decision‐making process on diagnostic testing for dementia in general practice. Key points: Most Dutch patients who seek help for memory complaints from their general practitioner (GP) for the first time are not referred for specialized diagnostic testing, which underlines the crucial and gatekeeper role GPs play in the management and care for this patient group.Previous qualitative research indicates that GPs consider patient characteristics important in decisions on diagnostic trajectories for memory complaints. Retrospective data from the studied electronic patient records, however, indicates that patient characteristics such as age and comorbidity do not differ between diagnostic strategies nor are they predictive for referrals.Further unraveling of the complex decision‐making process for diagnostic testing for dementia is needed to facilitate timely dementia diagnoses. [ABSTRACT FROM AUTHOR]

Background In older patients with end-stage kidney disease (ESKD), the choice between kidney transplantation (KT) and dialysis may be more complex than in younger patients because of a higher prevalence of comorbidities and frailty. This study aims to provide greater insight into the current decision-making process by exploring the expectations, experiences and health outcome priorities of all stakeholders. Methods We performed semi-structured interviews with patients ≥65 years with ESKD (eGFR <15 ml/min/1.73m2, KT recipient or treated with dialysis), patients' relatives and healthcare professionals (nephrologists, nurses and medical social workers). Interviews were conducted until data saturation and thematically analysed. Results We performed 36 interviews (patients n  = 18, relatives n  = 5, healthcare professionals n  = 13). Thematic analysis revealed five themes. Older patients' health outcome priorities were mostly related to quality of life (QOL). Individual older patients showed marked differences in the preferred level of engagement during the decision-making process (varying from 'wants to be in the lead' to 'follows the nephrologist') and in informational needs (varying from evidence-based to experience-based). On the contrary, healthcare professionals were quite unanimous on all aspects. They focused on determining eligibility for KT as start of the decision-making process, on clear and extensive information provision and on classical, medical outcomes. Conclusions The decision-making process could benefit from early identification of older patients' values, needs and health outcome priorities, in parallel with assessment of KT eligibility and before discussing the treatment options, and the explicit use of this information in further steps of the decision-making process. [ABSTRACT FROM AUTHOR]

• Being never or previously married relates to innate immunity, especially in males. • Unmarried older adults have higher plasma levels of amyloid-β40 and total tau. • Single older males have higher levels of all plasma neurodegeneration markers. • Immunity did not mediate the link between social health and global cognition. • Marital status and immunity interact to affect total brain volume in older age. The immune system has been proposed to play a role in the link between social health and all-cause dementia risk. We explored cross-sectional and longitudinal associations between social health, immune system balance and plasma neurodegeneration markers in community-dwelling older adults, and explored whether the balance between innate and adaptive immunity mediates associations between social health and both cognition and total brain volume. Social health markers (social support, marital status, loneliness) were measured in the Rotterdam Study between 2002–2008. Immune system cell counts and balance were assessed repeatedly from 2002 to 2016 using white blood-cell-based indices and individual counts (granulocyte-to-lymphocyte ratio (GLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII)). Plasma neurodegeneration biomarkers (amyloid-β40, amyloid-β42, total tau and neurofilament light chain) were measured once from blood samples collected between 2002–2008. Global cognitive function and total brain volume (MRI) were measured at the follow-up visit between 2009–2014. We used linear mixed models to study longitudinal associations and performed causal mediation analyses. In 8374 adults (mean age 65.7, 57 % female), never married participants (n = 394) had higher GLR, PLR and SII compared to married peers at baseline and during follow-up, indicating imbalance towards innate immunity. Being never married was associated with higher plasma amyloid-β40, and being widowed or divorced with higher plasma total tau levels at baseline. Widowed or divorced males, but not females, had higher GLR, PLR and SII at baseline. Higher social support was associated with lower PLR in females, but higher PLR in males. Loneliness was not associated with any of the immune system balance ratios. Never married males had higher levels of all plasma neurodegeneration markers at baseline. Immune system balance did not mediate associations between social health and cognition or total brain volume, but does interact with marital status. This study indicates that marital status is associated with blood-based immune system markers toward innate immunity and higher levels of plasma neurodegeneration markers. This is particularly evident for never married or previously married male older adults compared to married or female peers. [ABSTRACT FROM AUTHOR]

Background: Advance care planning (ACP) is becoming increasingly important in medical care. Some suggest standardized approaches to initiate ACP with all older adults. However, the idea of patient-centered care suggests more nuanced approaches tailored to individual older adults' needs. This study investigated how older adults with different views and needs about ACP can be approached in an adequate and most beneficial way by health care professionals. Methods: We used questionnaires, interviews, focus groups and informal conversations with older adults, living in their own homes, who volunteered to take part in our research. The research was participatory as we collaborated closely with practice partners and we used the obtained findings immediately and continuously to inform the next steps of our research throughout the process. Results: We identified three subgroups of older adults with differential needs regarding ACP-related activities: The first group avoids talking about their needs and wishes for care towards the end of life. These older people benefit from activities, which aim at motivating them to concern themselves with ACP-related topics. The second group consists of older adults who are in principle open for ACP-conversations but do not initiate these themselves. This group either trusts their next-of-kin or their healthcare professional to act in accordance with their wishes or does not bring up the topic in order to avoid confronting relevant others with possibly unpleasant topics. This group of people benefits from information about ACP and from healthcare professionals initiating the ACP process. The third group of older people initiates the ACP process themselves, gathers information, and takes the necessary steps for ACP. With this group it remains relevant to check carefully whether they have indeed taken all relevant steps and shared the information with all relevant involved care institutions and relatives. Conclusions: We propose a model to simplify adjustments of ACP to individuals' needs. Our suggested approach might contribute to increasing the motivation of older people to engage in ACP conversations if these are more closely related to their own needs. Further, it might also contribute to simplifying the individual shaping of the ACP process for healthcare professionals as our suggested model offers clear guidance for approaching different types of older people in different ways. The suggested approach may in future be used for training health care professionals in the conduct of ACP conversations. [ABSTRACT FROM AUTHOR]

Background: Relocations within and between nursing homes often induce stress, anxiety, and depression in residents and cause additional workload for and burnout in staff. To prevent this, many nursing homes deploy pre-transition initiatives, bridging initiatives, and post-transition initiatives to support residents and staff during the relocation process. As little is known about these initiatives, this study aims to explore the pre-relocation, bridging and post-relocation initiatives used for relocations within and between nursing homes. Methods: In seven Dutch nursing homes, eight focus groups were conducted with two to six participants (N = 37) who were actively involved in relocation processes in different roles (i.e., managers, healthcare professionals, support staff, client council members, residents and family). The focus groups were conducted based on a predefined topic list and lasted approximately 60 min. The transcripts were recorded, transcribed verbatim and analysed using thematic coding. Results: Nursing homes had to be inventive in developing relocation initiatives as neither shared guidelines nor knowledge exchange on this topic were available. A total of thirty-seven relocation initiatives were identified in these seven nursing homes. Nineteen pre-relocation initiatives were identified, of which eight emphasized information and engagement, three highlighted training and practice and eight stressed orientation and visualization. Seven bridging initiatives were identified, of which four emphasized coordination and continuity and three highlighted entertainment and celebration. Eleven post-relocation initiatives were identified, of which seven emphasized evaluation and troubleshooting and four highlighted change and adjustment. Conclusion: The identified relocation initiatives were developed unassisted by nursing homes, due to a lack of shared guidelines, knowledge exchange and mutual learning on this topic. Therefore, it may be expedient and more effective to develop general guidelines for relocations within and between nursing homes in collaboration with nursing homes. [ABSTRACT FROM AUTHOR]

Background This study aims to provide greater insight into the current decision-making process on diagnostic testing for dementia by exploring the expectations, needs and experiences of patients with memory complaints, significant others and general practitioners (GPs). Methods We performed semi-structured interviews with patients (>60 years) who consulted their GP on memory complaints, significant others and GPs. Participants were recruited until data saturation was reached in thematic analysis of interview transcripts. Results We performed 51 interviews (patients n  = 20, significant others n  = 15, GPs n  = 16). Thematic analysis revealed four themes: (i) 'drivers to (not) testing', i.e. need to act on symptoms, beliefs on the necessity and expected outcomes of diagnostic testing; (ii) 'patient preferences and context are critical in the actual decision', i.e. in the actual decision-making process interpretation of symptoms, GPs' desire to meet patient preferences, social context and healthcare system dynamics guided the decision; (iii) 'need for individualised communication in the decision-making process', i.e. for patients feeling heard was a prerequisite for decision-making and GPs tailored communication strategies to individual patients and (iv) 'GP practice and barriers to shared decision-making (SDM)', i.e. although GPs value SDM in the decision on diagnostic testing for dementia, patients express limited awareness of the decision and options at stake. Conclusions Decision-making on diagnostic testing for dementia is a multifactorial and preference-guided process for all involved stakeholders, but decisions are often not explicitly jointly made. Development of patient decision aids could facilitate better involvement and more informed choices by patients. [ABSTRACT FROM AUTHOR]

Introduction: In this study, we examine whether social health markers measured at baseline are associated with differences in cognitive capability and the rate of cognitive decline over an 11-to-18-year period among older adults and compare results across studies. Methods: We applied an integrated data analysis approach to 16,858 participants (mean age 65 years; 56% female) from the National Survey for Health and Development (NSHD), the English Longitudinal Study of Aging (ELSA), the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K), and the Rotterdam Study. We used multilevel models to examine social health in relation to cognitive capability and the rate of cognitive decline. Results: Pooled estimates show distinct relationships between markers of social health and cognitive domains, e.g., a large network size (≥6 people vs. none) was associated with higher executive function (0.17 standard deviation [SD] [95% CI: 0.00, 0.34], I2 = 27%) but not with memory (0.08 SD [95% CI: −0.02, 0.18], I2 = 19%). We also observed pooled associations between being married or cohabiting, having a large network size, and participating in social activities with slower decline in cognitive capability. However, estimates were close to zero, e.g., 0.01 SD/year (95% CI: 0.01, 0.02) I2 = 19% for marital status and executive function. There were clear study-specific differences: results for average processing speed were the most homogenous, and results for average memory were the most heterogeneous. Conclusion: Overall, markers of good social health have a positive association with cognitive capability. However, we found differential associations between specific markers of social health and cognitive domains and differences between studies. These findings highlight the importance of examining between-study differences and considering the context specificity of findings in developing and deploying interventions. [ABSTRACT FROM AUTHOR]

Background: Persons with dementia are at risk of developing nutritional problems. Theoretical models on nutritional problems have been developed, but have not been evaluated with healthcare professionals. Objective: This study aimed to explore the comprehensiveness and applicability of a theoretical model of nutritional problems in persons with dementia for daily nursing home practice. Methods: A qualitative design employing a combined deductive and inductive approach was used. Healthcare professionals were eligible to participate if they 1) had expert knowledge of and experience with nutritional problems related to dementia, and 2) worked in a nursing home affiliated with an academic network covering the east and south of the Netherlands. Three focus group interviews with 20 healthcare professionals from seven professions were held. We conducted thematic analysis and we compared themes with existing theoretical models from the literature. Results: We identified six themes, four of which corresponded with the existing models (observing and analysing nutritional problems; consequences of nutritional problems; functioning of the person with dementia; environmental factors). Interprofessional collaboration and ethical factors were identified as new themes. The analyses indicated interactions within each theme, between themes, and a bidirectional connection between themes. Conclusions: This study demonstrated the relevance of interprofessional collaboration and ethical considerations in nutritional problems related to dementia. It uncovered complex bidirectional relations within and between factors regarding nutritional problems. All aspects should be taken into account to minimize the consequences of nutritional problems for persons with dementia. [ABSTRACT FROM AUTHOR]

The concept of resilience, i.e., the capacity of a system to bounce back after a stressor, is gaining interest across many fields of science, policy, and practice. To date, resilience research in people with cognitive decline has predominantly addressed the early stages of decline. We propose that: (1) resilience is a relevant concept in all stages of cognitive decline; and (2) a socio-ecological, multisystem perspective on resilience is required to advance understanding of, and care and support for people with cognitive decline and their support networks. We substantiate our position with literature and examples. Resilience helps understand differences in response to risk factors of (further) cognitive decline and informs personalised prevention. In a curative context, interventions to strengthen resilience aim to boost recovery from cognitive decline. In care for people with dementia, resilience-focused interventions can strengthen coping mechanisms to maintain functioning and well-being of the individual and their support network. A good example of improving resilience in the social and policy context is the introduction of age-friendly cities and dementia-friendly communities. Good care for people with cognitive decline requires a health and social care system that can adapt to changes in demand. Given the interdependency of resilience at micro-, meso- and macro-levels, an integrative socio-ecological perspective is required. Applying the concept of resilience in the field of cognitive decline opens new horizons for research to improve understanding, predicting, intervening on health and social care needs for the increasing population with cognitive decline. [ABSTRACT FROM AUTHOR]

To explore the preferences of people with memory complaints (PwMC) and their significant others regarding starting a diagnostic trajectory for dementia. A systematic literature search was conducted in PubMed, PsycINFO, CINAHL, Web of Science, and Embase. Selection of abstracts and papers was performed independently by two researchers. Methodological quality was assessed with the Mixed Method Appraisal Tool. Result sections of the selected papers were thematically synthesized. From 2497 citations, seven qualitative studies and two mixed methods studies published between 2010 and 2020 were included. Overall quality of the studies was high to moderate. A thematic synthesis showed that preferences for starting a diagnostic trajectory arose from the feeling of needing to do something about the symptoms, beliefs on the necessity and expected outcomes of starting a diagnostic trajectory. These views were influenced by normalization or validation of symptoms, the support or wishes of the social network, interactions with health care professionals, the health status of the PwMC, and societal factors such as stigma and socioeconomic status. A variety of considerations with regard to decision-making on starting a diagnostic trajectory for dementia were identified. This emphasizes the need to explore individual preferences to facilitate a timely dementia diagnosis. [ABSTRACT FROM AUTHOR]

Communication and coordination between primary healthcare professionals and informal caregivers involved in the care for frail older adults is suboptimal and could benefit from interprofessional digital communication tools. Implementation in daily practice however frequently fails. We aim to identify generic barriers and facilitators experienced by healthcare professionals and informal caregivers during implementation of interprofessional communication tools to improve their long-term use. Qualitative content analysis using individual semi-structured interviews was used for evaluating three different digital communication tools used by interprofessional primary care networks for frail older adults by 28 professionals and 10 caregivers. After transcription and open coding, categories and themes were identified. Barriers and facilitators were related to: tool characteristics, context of use, involvement of professionals and caregivers. The tool improved availability, approachability and users' involvement. The large number of digital systems professionals simultaneously use, and different work agreements hampered tool use. The tools facilitated care coordination, and professionals declared to be better informed about patients' current situations. Overall, interprofessional digital communication tools can facilitate communication in networks for primary elderly care. However, integration between digital systems is needed to reduce the number of tools. Organizations and policy makers have an important role in realizing the tools' long-term use. [ABSTRACT FROM AUTHOR]

Introduction: Care integration in primary elderly care is suboptimal. Validated instruments are needed to enable the implementation of integrated primary care. We aimed to assess construct validity of the Rainbow Model of Integrated Care measurement tool (RMIC-MT) for healthcare professionals working in an integrated primary elderly care setting in the Netherlands. Methods: In a cross-sectional study, the RMIC-MT, a 36-item questionnaire covering all domains of the Rainbow Model of Integrated Care (RMIC), was sent out to local networks of primary elderly care professionals. Confirmatory factor analysis with maximum likelihood estimation was used for the validation of the factor structure the RMIC-MT. Model fit was assessed by the chi-square test and fit indices. Results: The RMIC-MT was completed by 323 professionals, primarily general practitioners, community nurses, practice nurses, and case managers. Confirmatory factor analysis and corresponding fit indices showed moderate to good fit, thereby confirming a nine factor model with a total of 36 items. Conclusions: The RMIC-MT is promising for the primary elderly care setting in the Netherlands. It can be used for evaluating integrated care initiatives in a primary care setting, thereby contributing to implementation of integrated primary elderly care. [ABSTRACT FROM AUTHOR]

Purpose: Prehabilitation is increasingly offered to patients with colorectal cancer (CRC) undergoing surgery as it could prevent complications and facilitate recovery. However, implementation of such a complex multidisciplinary intervention is challenging. This study aims to explore perspectives of professionals involved in prehabilitation to gain understanding of barriers or facilitators to its implementation and to identify strategies to successful operationalization of prehabilitation. Methods: In this qualitative study, semi-structured interviews were performed with healthcare professionals involved in prehabilitation for patients with CRC. Prehabilitation was defined as a preoperative program with the aim of improving physical fitness and nutritional status. Parallel with data collection, open coding was applied to the transcribed interviews. The Ottawa Model of Research Use (OMRU) framework, a comprehensive interdisciplinary model guide to promote implementation of research findings into healthcare practice, was used to categorize obtained codes and structure the barriers and facilitators into relevant themes for change. Results: Thirteen interviews were conducted. Important barriers were the conflicting scientific evidence on (cost-)effectiveness of prehabilitation, the current inability to offer a personalized prehabilitation program, the complex logistic organization of the program, and the unawareness of (the importance of) a prehabilitation program among healthcare professionals and patients. Relevant facilitators were availability of program coordinators, availability of physician leadership, and involving skeptical colleagues in the implementation process from the start. Conclusions: Important barriers to prehabilitation implementation are mainly related to the intervention being complex, relatively unknown and only evaluated in a research setting. Therefore, physicians' leadership is needed to transform care towards more integration of personalized prehabilitation programs. Implications for cancer survivors: By strengthening prehabilitation programs and evidence of their efficacy using these recommendations, it should be possible to enhance both the pre- and postoperative quality of life for colorectal cancer patients during survivorship. [ABSTRACT FROM AUTHOR]

Dementia is a clinical diagnosis without curative treatment. It is uncertain whether ancillary testing is beneficial for patients. This study investigates the association between use of diagnostic tests and time to poor outcome and health care costs. Nationwide register-based cohort study using health care reimbursement data in the Netherlands. All Dutch hospitals, including 13,312 patients diagnosed with dementia in 2018. Diagnostic testing included computed tomography or magnetic resonance imaging (CT/MRI), neuropsychological examination (NPE), nuclear imaging (PET/SPECT), electroencephalography (EEG), and cerebrospinal fluid (CSF) testing. We compared time to poor outcome (institutionalization or death) and costs per month from 2018 to 2021 between those who underwent a specific diagnostic test in previous years to controls, propensity score matched for age, sex, type of hospital, and comorbidity. Time to poor outcome in those who underwent CT/MRI, EEG, or CSF testing was similar to those who did not, but was longer for those who underwent NPE. Time to poor outcome was shorter in patients who underwent PET/SPECT. Patients who underwent CSF testing or PET/SPECT had higher mean total health care costs as compared to controls (CSF €248, 95% CI 64-433; PET/SPECT: €315, 95% CI 179-451). NPE during the diagnostic trajectory was associated with lower total health care cost (–€127, 95% CI –62, –193). NPE was associated with longer time to poor outcome and lower health care costs, potentially due to confounding by indication. Patients who underwent neuroimaging (CT, MRI, SPECT/PET), CSF testing, or EEG for dementia diagnostics did not experience a longer time to poor outcome or lower health care costs. This emphasizes the importance of clinical examination as anchor for the diagnosis of dementia. [ABSTRACT FROM AUTHOR]

Background: Sporadic cerebral amyloid angiopathy (sCAA) research of the past decade has increasingly focused on developing biomarkers that allow for an earlier and more accurate sCAA-diagnosis. Considering that sCAA does not have treatment options available (yet), more fundamental questions concerning the desirability of using such early-sCAA biomarkers in clinical practice need to be addressed.Objective: In this qualitative interview study, we aim to explore the views of vascular neurologists on the purpose and possible consequences of an earlier and more accurate sCAA-diagnosis, using new biomarkers.Methods: Vascular neurologists from around the world were approached via email and interviewed via video call. Topics included views on current sCAA diagnostic practice, considerations on the use of new biomarkers, and expectations and hopes for the future. All interviews were transcribed ad verbatim using a transcription program (Otter.ai). Transcripts were analyzed using inductive content analysis.Results: We interviewed 14 vascular neurologists. Views regarding the desirability of new sCAA-biomarkers differed substantially between interviewees as to when and in whom these biomarkers could be of benefit in clinical practice. These differences were mainly reported with regards to prognosis, risk stratification, and biological precision, between general stroke neurologists and neurologists with specific sCAA-expertise.Conclusion: Views on the use of sCAA-biomarkers in clinical practice differ substantially between vascular neurologists. There is particularly no consensus regarding when, and in whom sCAA biomarkers could be useful in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Patients with incurable cancer face complex medical decisions. Their family caregivers play a prominent role in shared decision making processes, but we lack insights into their experiences. In this study, we explored how bereaved family caregivers experienced the shared decision making process. Methods: We performed a qualitative interview study with in-depth interviews analysed with inductive content analysis. We used a purposive sample of bereaved family caregivers (n = 16) of patients with cancer treated in a tertiary university hospital in the Netherlands. Results: Four themes were identified: 1. scenarios of decision making, 2. future death of the patient 3. factors influencing choices when making a treatment decision, and 4. preconditions for the decision making process. Most family caregivers deferred decisions to the patient or physician. Talking about the patient's future death was not preferred by all family caregivers. All family caregivers reported life prolongation as a significant motivator for treatment, while the quality of life was rarely mentioned. A respectful relationship, close involvement, and open communication with healthcare professionals in the palliative setting were valued by many interviewees. Family caregivers' experiences and needs seemed to be overlooked during medical encounters. Conclusions: Family caregivers of deceased patients with cancer mentioned life prolongation, and not quality of life, as the most important treatment aim. They highly valued interactions with the medical oncologist and being involved in the conversations. We advise medical oncologists to take more effort to involve the family caregiver, and more explicitly address quality of life in the consultations. [ABSTRACT FROM AUTHOR]

Background: Patients with incurable cancer face complex medical decisions. Their family caregivers play a prominent role in shared decision making processes, but we lack insights into their experiences. In this study, we explored how bereaved family caregivers experienced the shared decision making process. Methods: We performed a qualitative interview study with in-depth interviews analysed with inductive content analysis. We used a purposive sample of bereaved family caregivers (n = 16) of patients with cancer treated in a tertiary university hospital in the Netherlands. Results: Four themes were identified: 1. scenarios of decision making, 2. future death of the patient 3. factors influencing choices when making a treatment decision, and 4. preconditions for the decision making process. Most family caregivers deferred decisions to the patient or physician. Talking about the patient's future death was not preferred by all family caregivers. All family caregivers reported life prolongation as a significant motivator for treatment, while the quality of life was rarely mentioned. A respectful relationship, close involvement, and open communication with healthcare professionals in the palliative setting were valued by many interviewees. Family caregivers' experiences and needs seemed to be overlooked during medical encounters. Conclusions: Family caregivers of deceased patients with cancer mentioned life prolongation, and not quality of life, as the most important treatment aim. They highly valued interactions with the medical oncologist and being involved in the conversations. We advise medical oncologists to take more effort to involve the family caregiver, and more explicitly address quality of life in the consultations. [ABSTRACT FROM AUTHOR]

Dysregulation of the negative feedback loop of the hypothalamic-pituitary-adrenal (HPA) axis may have damaging effects on the brain, potentially under influence of psychosocial health factors. We studied associations between functioning of the negative feedback loop of HPA-axis, measured with a very low-dose dexamethasone suppression test (DST), and brain structure in middle-aged and older adults, and whether these associations were modified by psychosocial health. From 2006 to 2008, 1259 participants (mean age 57.6 ± 6.4, 59.6 % female) of the population-based Rotterdam Study completed a very low-dose DST (0.25 mg) and underwent magnetic resonance imaging (MRI) of the brain. Self-reported psychosocial health (depressive symptoms, loneliness, marital status, perceived social support) were assessed in the same time period. Multivariable linear and logistic regression were used to study cross-sectional associations between cortisol response and brain volumetrics, cerebral small vessel disease markers and white matter structural integrity. To assess the effect of psychosocial health on these associations, analyses were further stratified for psychosocial health markers. Cortisol response was not associated with markers of global brain structure in the overall study sample. However, in participants with clinically relevant depressive symptoms, a diminished cortisol response was associated with smaller white matter volume (mean difference: − 1.00 mL, 95 %CI = − 1.89;− 0.10) and smaller white matter hyperintensity volume (mean difference: − 0.03 mL (log), 95 %CI = − 0.05;0.00). In participants with low/moderate perceived social support compared to those with high social support, a diminished cortisol response was associated with larger gray matter volume (mean difference: 0.70 mL, 95 %CI = 0.01;1.39) and higher fractional anisotropy (standardized mean difference 0.03, 95 %CI = 0.00;0.06). Diminished function of the HPA-axis is differently associated with brain structure in community-dwelling middle-aged and older adults with clinically relevant depressive symptoms or suboptimal social support, but not in adults without depressive symptoms or with optimal social support. • Cortisol response after a DST is not associated with global brain structure. • In depression, diminished cortisol response associated with worse brain structure. • With low social support, reduced cortisol response is linked to better brain health. [ABSTRACT FROM AUTHOR]

Introduction: Implementing integrated care in primary care settings is essential to establish a sustainable health care system for older adults living at home. Measuring integrated care performance facilitates implementation and improvement of integrated care services in daily practice, yet valid instruments are still lacking. Based on the Rainbow Model of Integrated Care (RMIC) a measurement tool (MT) has been validated for renal care patients and care providers. In the present study we aimed to validate the RMIC-MT for healthcare professionals working in an integrated primary elderly care setting. Theory/Methods: The RMIC-MT is a 36-item questionnaire, covering all aspects of integrated care according to the RMIC. Per integration domain professionals are asked to rate a set of questions. In a cross-sectional study, the RMIC-MT was sent to local networks of primary elderly care professionals in the Netherlands by email between February 2020 and February 2021. Confirmatory factor analysis (CFA) was used to build upon the previous results of the RMIC-MT for renal care by using the standard fit indices: root-mean-square error of approximation (RMSEA) (=0.06), standardized root-mean-square residual (SRMR) (=0.08), comparative fit index (CFI) (=0.90) and Tucker-Lewis index (TLI) (=0.90). Maximum likelihood was used to estimate the model parameters and goodness-of-fit indices. Results: 323 professionals filled out the RMIC-MT, the majority were general practitioners, community nurses, practice nurses and case managers. Median time needed to complete the RMIC-MT was 14 minutes. Some professionals did not complete the questionnaire because the questionnaire was too long or perceived as irrelevant. The model passed the goodness-to-fit test by confirmatory factor analysis: RMSEA=0.046, SRMR=0.055, CFI=0.895, TLI=0.882. The factor structure of 9 categories with a total of 36 items was thereby confirmed. Conclusions: We successfully validated the RMIC-MT for the primary elderly care setting. We adjusted the name of one category from 'triple aim' to 'outcome measurements'. Application of the RMIC-MT enables professional networks in this setting to evaluate and improve their care integration and contribute to better quality and more sustainable primary elderly care. Implications for applicability/transferability, sustainability, and limitations: The sample size was small but sufficient for the CFA. Recruitment was difficult which may reflect difficulties in future use in daily practice. The RMIC-MT was considered too long by some professionals. Developing a shorter version may be a promising strategy to increase completion in daily practice. RMIC-MT application can enable professionals to improve people-centered integrated primary care by using the feedback reports for improvement plans. Feasibility and added value of the tool should be studied after this small-scale implementation. Broader implementation of the RMIC-MT for elderly care should be investigated, including other contexts and countries. [ABSTRACT FROM AUTHOR]

Introduction: Rearrangements in primary care are needed to cope with aging populations, resulting in an increased prevalence of dementia and increasing health care costs. An essential strategy to establish a sustainable health care system for people with dementia is implementing integrated care in primary care settings. With DementiaNet, an integrated network-based approach, we facilitated collaboration between healthcare professionals from medical, care and social domains, and helped increasing their dementia expertise. Our aim is to evaluate the effects of the DementiaNet approach on quality of care, network collaboration and number of crisis admissions. Theory/Methods: In a longitudinal mixed methods multiple case study, 34 primary care networks participated; they adopted the DementiaNet approach in which a two-year tailor-made program was offered. Networks started between 2015 and 2020 and follow-up ended in 2021. Yearly, networks participated in data collection on their self-reported quality of care and crisis situations. Network collaboration was assessed yearly with scores on the eight integration domains of the Rainbow Model of Integrated Care based on semi-structured interviews with network leader(s). Descriptive statistics were used to identify changes in mean scores over time. Network characteristics and interview data was used to gain deeper understanding of the quantitative outcomes. Linear mixed models will be used to analyze the differences over time for quality of care and network collaboration. Results: Networks consisted on average of nine professionals (mainly a general practitioner, community nurse, practice nurse and case manager). Follow-up was 2-6 years. On average, quality of care of the networks increased for all measured indicators, of which the percentage of people discussed in a multidisciplinary meeting increased the most from 55% (range 0-100%) to 80% (range 48-100%). Advanced networks had less crisis situations compared to starting networks, 25% versus 30% (p=0.038) of their caseload of persons with dementia had a crisis situation. The quality of care was not associated with the number of crisis situations. Network collaboration increased as well over time and these results sustained or further improved after the two-year program ended. Conclusions: The DementiaNet approach improved quality of care and network collaboration and decreased the number of crisis situations of local primary dementia care networks. These effects sustained after the two-year program ended. Because of the improved collaboration, more advanced networks may be able to better communicate and act sooner in case of an oncoming crisis. Implications for applicability/transferability, sustainability, and limitations: Evaluation of a complex program such as DementiaNet requires an innovative design, flexibility and time. Previous studies did not find improvements after implementing integrated care, we showed that these improvements take at least two years to establish. Nevertheless, these effects were successfully sustained by the networks after the two years of support. Data is partly self-reported by network members. Despite the detailed data-collection protocols and definitions that were provided, the quality of the data may have suffered because of this strategy. Future research should focus on identifying if the DementiaNet approach is able to decrease healthcare costs. [ABSTRACT FROM AUTHOR]

Introduction Crisis admissions of persons with dementia are more prevalent due to the rising number of people with dementia living longer at home. Better collaboration between primary care professionals could prevent crisis situations. Therefore, the DementiaNet program focuses on a transition towards integrated care by supporting interdisciplinary networks of primary care professionals from the medical, care and social services to improve their collaboration. This study aims to determine the effect of the DementiaNet program on the number of crisis admissions. Theory/Methods DementiaNet networks started from 2015 onwards. This 2-year program is based on the Rainbow Model of Integrated Care and consists of coaching and support to help the networks go from ad hoc collaboration to a structured collaboration. Collaboration, network leadership, interdisciplinary education and quality improvement cycles are key elements to help networks improve their quality of care for the persons with dementia and their caregivers. Yearly, networks collect patient data on five quality of care indicators, and on admission to a hospital or nursing home due to a crisis. The data collection took place between 2015 and 2020. We compared the number of crisis admissions of advanced networks (>2 years active) with the number of crisis admissions of starting networks (<2 years active) by using an independent T-test. Logistic regression was used to determine the relation between quality of care and the number of crisis admissions. Result 34 networks with on average 9 professions (frequently: general practitioner, practice nurse, community nurse and case manager) were included. The networks collected data of 1689 patient years of which 479 patient years had a crisis. Preliminary results show that advanced networks had less crisis admissions than starting networks, 0.25 versus 0.30 respectively (p=0.038, CI=0.003 - 0.091). The quality of care was not associated with the number of crisis situations. Discussions In advanced networks, less crisis admissions took place; Surprisingly, this effect was not mediated by quality of care. A possible explanation is that better collaboration leads to less crisis admissions due to earlier intervention by professionals. Conclusions The Dementia program was able to facilitate a transition towards better interdisciplinary collaboration within networks of primary dementia care professionals. In advanced networks less crisis admissions occurred than in starting networks. The quality of care was not associated with the number of crisis admissions. Lessons learned A complex intervention, such as DementiaNet, is able to realize a transition towards network-based care and enhance interdisciplinary collaboration to reduce the number of crisis admissions. Limitations The dataset consists of patient years rather than patients, data was collected yearly and we were not able to adjust for the same persons present in the dataset several years in a row. Ideally, we would like to include patient trajectories in further research. Suggestions for future research Further research in a larger database could contribute to unravelling the complex relations between network maturity, quality of care and crisis admissions in primary dementia care. [ABSTRACT FROM AUTHOR]

Introduction Crisis admissions of persons with dementia are more prevalent due to the rising number of people with dementia living longer at home. Moreover, societal dependency on informal care grows, which negatively impacts caregivers' wellbeing. This is often a direct reason for crisis admission of the person with dementia. Therefore, we developed REMIND, a digital tool for frequent monitoring of wellbeing and resilience of caregivers, which enables case managers to provide timely support, thereby preventing deterioration in caregiver wellbeing and eventually crisis admissions. The aim of this pilot study is to explore the usability and acceptability of REMIND. Theory/Methods During a 3-month period case manager-caregiver duo's used REMIND. The monitor was developed in co-creation with end-users during focus groups. The pilot version of REMIND consisted of a weekly set of questions on social support, reciprocity, burden, wellbeing, own activities and small crises, filled in via a chat on a smartphone or computer. Caregiver wellbeing was displayed in graphs on a dashboard for case managers to act upon. Usability and acceptability of the tool were explored in semi-structured interviews with the caregivers and case managers. Two independent researchers applied content analysis on the transcripts. Results Eight case managers and fourteen caregivers participating considered the tool easy to use. Caregivers appreciated REMIND, because it stimulated self-reflection regarding the burden of their caregiving processes. Case managers valued the tool's ability to gain better insight in the actual wellbeing of caregivers, because some caregivers find it hard to acknowledge themselves being burdened during a face-to-face conversation. The fact that REMIND provided insight in wellbeing patterns over time instead of a single assessment during a monthly home visit, was highly appreciated by case managers. The monitor outcomes were therefore considered a suitable starting point for conversations with caregivers. Suggestions for improvements included, more diverse set of questions and additional functions including peers support. Discussions In this pilot, REMIND was found highly usable and acceptable for both caregivers and casemanagers. The use a co-design approach in the development likely contributed to these findings. Conclusions Pilot evaluation of digital monitor for caregivers and case managers showed that the tool was easy to use and stimulated self-reflection in caregivers. For case managers it provided a starting point for conversations. The tool is able to monitor wellbeing of caregivers and thereby has the potential to prevent crisis. Lessons learned Developing a monitoring tool for caregivers of persons with dementia in a co-creation design process with end-users led to a well-accepted and easy-to-use device. Limitations Casemanagers in this pilot study were early adopters. Further research should include a more diverse group of case managers. Suggestions for future research A future randomized controlled study with longer follow-up may determine whether its use prevents (small) crises. [ABSTRACT FROM AUTHOR]

The complex care needs of frail older persons living at home is a major challenge for health care systems worldwide. One possible solution is to employ a primary care physician (PCP) with additional geriatric expertise. In the Netherlands, elderly care physicians (ECPs), who traditionally work in nursing homes, are increasingly encouraged to utilize their expertise within primary care. However, little is known about how PCPs and ECPs collaborate. Therefore, we aimed to unravel the nature of the current PCP-ECP collaboration in primary care for frail older persons, and to identify key concepts for success. A qualitative multiple case study with semistructured interviews. A selection of 22 participants from 7 "established collaboration practices" within the primary care setting in the Netherlands, including at least 1 ECP, 1 PCP, and 1 other health care professional for every included established collaboration practice. Transcripts of individual interviews were analyzed using largely double and independent open and axial coding, and formulation of themes and subthemes. Data analysis revealed 4 key concepts for success: (1) clarification of roles and expectations (ie, patient-centered care and embedding in existing care networks), (2) trust, respect, and familiarity as drivers for collaboration (ie, mutual trust through knowing each other and having shared goals); (3) framework for regular communication (ie, structural meetings and a shared vision); and (4) government, payer, and organization support (ie, financial support and emphasis on the collaboration's urgency by organizations and national policy makers). For a successful generalist-specialist collaboration, health care professionals need to invest in building relationships and mutual trust, and incorporating their efforts in the existing care networks to guarantee patient-centeredness. When provided with reimbursement and appreciation, this collaboration is a promising change in general practice to improve the care and outcomes of frail older persons. [ABSTRACT FROM AUTHOR]