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Objectives To assess neuropsychiatric symptoms and quality of life in a group of patients in the final phase of dementia. Methods All patients with dementia (n = 216) residing on dementia special care units of two Dutch nursing homes were included in the study provided they met the criteria for the final phase of dementia. Neuropsychiatric symptoms were assessed with the Neuropsychiatric Inventory Nursing Home version (NPI-NH) and the Cohen Mansfield Agitation Inventory (CMAI). Quality of life was assessed with the QUALIDEM Results Of the 216 dementia patients 39 met the criteria for the final phase of dementia. The patients showed a specific pattern of behaviours with a high prevalence of apathy, agitation and behaviours that were mainly observed during morning care such as making strange noises, grabbing, performing repetitious mannerism, spitting, hitting, screaming and pushing. Overall quality of life of these patients in the final phase of dementia was moderate. Conclusion In this small sample, patients in the final phase of dementia show specific behavioural problems, that mainly should be addressed with psychosocial interventions. Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives To investigate the causes of death in nursing home patients with dementia, and to compare causes of death in patients who survive until the final phase of dementia with those who die before reaching that phase, adjusted for potential confounders. Design Observational analysis of a cohort of patients with a prospective follow-up. Setting Psychogeriatric nursing home ‘Joachim en Anna’ in Nijmegen, the Netherlands. Participants Eight hundred and ninety dementia patients admitted between 1980 and 1989. All patients were followed until death. Measurements The final phase of dementia was defined as total impairment on 20 items of a functional status questionnaire. Immediate causes of death (part 1a of the Dutch death certificate) were classified by the International Classification of Health Problems in Primary Care. Results The three most important reported immediate causes of death were cachexia/dehydration (35.2%), cardio-vascular disorders (20.9%) and acute pulmonary diseases (20.1%), mainly pneumonia. Cachexia/dehydration was particularly common as a cause of death of patients who survived to the final phase (53.2%); survival to the final phase of dementia was an independent predictor of cachexia/dehydration as an immediate cause of death with reference to cardiovasculair disorders in multinomial regression adjusted for age at death, gender, and type of dementia. Conclusion Patients who survive to the final phase of dementia are more likely to die from cachexia or dehydration than those who die before. The findings contribute to a debate on what should be reported as the immediate cause of death in dementia including perspectives from a palliative care viewpoint. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To investigate the determinants of survival to late dementia in Dutch nursing home patients. DESIGN: Observational analysis of a cohort of patients with a prospective follow-up. SETTING: Psychogeriatric nursing home “Joachim en Anna” in Nijmegen, the Netherlands. PARTICIPANTS: Dementia patients from a psychogeriatric nursing home admitted between 1980 and 1989. MEASUREMENTS: All patients were followed until death. Age, sex, severity of dementia on admission, and type of dementia were analyzed as determinants of survival to late dementia. Late dementia was operationally defined as total impairment on 20 items of the functional status questionnaire. RESULTS: The mean disease duration of the study population was 7.0 years, with a wide range. Some died soon after dementia was diagnosed, whereas others lived for more than 25 years after onset of the disease. One hundred twenty-six patients (14.2%) reached the phase of late dementia, most of whom were women (90%) with Alzheimer's disease (60%). For most of the patients, this phase lasted 1 year or less. Age, sex, type of dementia, and severity of dementia on admission all contributed significantly to predicting survival to late dementia. CONCLUSION: One of seven nursing home patients with dementia survived to late dementia. Nursing home physicians can use these findings to inform relatives about the prognosis. J Am Geriatr Soc 51:184–187, 2003. [ABSTRACT FROM AUTHOR]

One of the main reasons for people with dementia to move to a dementia special care unit of a nursing home is challenging behavior. This behavior is often difficult to manage, and in the Netherlands, residents are sometimes relocated to a severe challenging behavior specialized unit. However, relocation often comes with trauma and should be prevented if possible. This study aimed to investigate the patient- and context-related reasons for these relocations. Qualitative multiple case study using individual (n = 15) and focus group interviews (n = 4 with n = 20 participants) were held with elderly care physicians, physician assistants, psychologists, nursing staff members, and relatives involved with people with dementia and severe challenging behavior who had been transferred to a severe challenging behavior specialized unit. Audio recordings were transcribed and analyzed with thematic analysis, including directed content analysis. After five cases, data-saturation occurred. The thematic analysis identified three main processes: increasing severity of challenging behavior, increasing realization that the clients' needs cannot be met, and an increasing burden of nursing staff. The interaction between these processes, triggered mainly by a life-threatening situation, led to nursing staff reaching their limits, resulting in relocation of the client. Our study resulted in a conceptual framework providing insight into reasons for relocation in cases of severe challenging behavior. To prevent relocation, the increasing severity of challenging behavior, increasing burden on nursing staff, and increasing realization that the clients' needs cannot be met need attention. [ABSTRACT FROM AUTHOR]

Objectives: Young onset dementia (YOD) often comes with neuropsychiatric symptoms (NPS) that are burdening for patients and caregivers and are predictors for institutionalization. The course of NPS in institutionalized patients with YOD is unknown. This study aims to fill this gap. Method: This study is part of the BEYOND-study, a descriptive longitudinal cohort study of institutionalized YOD patients. Eighty-nine patients were included in this two-year follow-up study, of which 50 completed the whole follow-up. Clinically relevant NPS were assessed using the Neuropsychiatric Inventory-Nursing Home version with a threshold of FxS ≥4. Mean scores and prevalence were calculated of all patients alive at the moment of a given assessment. Cumulative percentages were calculated in patients with complete follow-up. Results: 82–94% of the residents had at least one NPS at any of the five assessments. Over the two year course, 94% of the patients developed at least one new symptom of which 58% developed irritability, 52% agitation, 44% disinhibition and 44% eating change. All patients had any NPS during follow-up. Apathy had the highest overall prevalence rate and was the most persistent symptom over the two-year course, followed by eating changes, aberrant motor behaviour and irritability. The course during follow-up was variable for all NPS with no clear increase or decrease. Conclusion: The severity and prevalence of NPS in institutionalized YOD patients fluctuated during follow-up. Apathy and hyperactive symptoms were most severe and persistent. Future research should focus on the influence of psychotropic drug use and dementia subtype on the course of NPS. [ABSTRACT FROM AUTHOR]

Objective: Several European studies investigated the trends in psychotropic drug prescriptions (PDPs) among nursing home (NH) residents and reported a decline in antipsychotics prescriptions. Since the Dutch long-term care system differs from other European systems (e.g. higher threshold for NH admission and trained elderly care physicians), this study explores the trends in PDPs in Dutch NH residents with dementia.Methods: The study used data from nine studies, comprising two cross-sectional studies, one cohort study, and six cluster-randomized controlled trials, collected in Dutch NHs between 2003 and 2018. With multilevel logistic regression analysis, NHs as a random effect, we estimated the trends in PDPs overall and for five specific psychotropic drug groups (antipsychotics, antidepressants, anxiolytics, hypnotics, and anti-dementia drugs), adjusting for confounders: age, gender, severity of dementia, severity of neuropsychiatric symptoms, and length of stay in NHs.Results: The absolute prescription rate of antipsychotics was 37.5% in 2003 and decreased (OR = 0.947, 95% CI [0.926, 0.970]) every year. The absolute prescription rate of anti-dementia drugs was 0.8% in 2003 and increased (OR = 1.162, 95% CI [1.105, 1.223]) per year. The absolute rate of overall PDPs declined from 62.7% in 2003 to 40.4% in 2018.Conclusions: Among Dutch NH residents with dementia, the odds of antipsychotics prescriptions decreased by 5.3% per year while the odds of anti-dementia drug prescriptions increased by 16.2%. There were no distinct trends in antidepressants, anxiolytics, and hypnotics prescriptions. However, overall PDPs were still high. The PDPs in NH residents remain an issue of concern. [ABSTRACT FROM AUTHOR]

Considering the limited availability of dermatologists to perform live consultations in nursing homes, teledermatology could be used as a triage tool for selection of cases for which live consultations are considered to be of added value compared with teledermatology. This prospective, multicentre observational study aimed to determine the reasons for dermatology consultations in nursing homes and the estimated value of teledermatology as a triage tool, including potential predictors. Skin tumours were the most common reason (n = 161/270; 59.6%) for dermatology consultations in nursing homes. Dermatologists estimated that live consultations added value compared with teledermatology in 67.8% of cases (n = 183). Multivariable logistic regression showed that predictors for this added value of live consultations were: consultations because of a skin tumour; consultations during which a diagnostic or treatment procedure was performed; consultations during which a secondary diagnosis was made; and the dermatologist involved. These results indicate that using teledermatology as a triage tool potentially reduces the need for additional live consultations in one-third of patients, whereas live consultations are estimated to have added value over teledermatology in two-thirds of cases. To make optimal use of the limited capacity for live consultations by dermatologists, it could therefore be helpful if elderly care physicians use teledermatology more frequently. [ABSTRACT FROM AUTHOR]

We investigated the 2-week prevalence and correlates of very frequent physical aggression (PA) and vocalizations in nursing home (NH)-residents with dementia. This cross-sectional study used combined data of 2074 NH-residents from four studies, collected from 119 dementia special care units in 26 Dutch NH. Very frequent PA was defined as scoring 6 or 7 on the items 'hitting', pushing', 'biting' and 'kicking' of the Cohen Mansfield Agitation Inventory; very frequent vocalizations as scoring 6 or 7 on 'screaming' and 'making strange noises'. We compared NH-residents with very frequent PA or vocalizations with residents with less frequent PA or vocalizations, assessing correlates using univariate and multivariate multilevel logistic regression analyses. We found a 2-week prevalence of 2.2% (95% confidence interval (CI): 1.63–2.89) of very frequent PA and 11.5% of very frequent vocalizations (95% CI: 10.23–12.98). Very frequent PA was only associated with apathy (odds ratio (OR)=1.93, 95% CI: 1.04–3.61). Correlates of very frequent vocalizations were age (OR = 0.97, 95% CI: 0.951–0.998), dementia severity (overall p-value 0.020), antipsychotic drug use (OR = 1.56, 95% CI: 1.08–2.26), antiepileptic drug use (OR = 2.75, 95% CI: 1.34–5.68) and euphoria (OR = 2.01, 95% CI: 1.22–3.31). Characteristics of NH-residents with very frequent PA or very frequent vocalizations differ from those of NH-residents with less frequent PA or vocalizations. Frontal lobe damage, boredom, pain and/or external factors may explain several of the found associations, but further research is necessary. Our findings may contribute to better care for these residents and thereby to improving their quality of life. [ABSTRACT FROM AUTHOR]

Aims: Establishing the prevalence of inappropriate sexual behaviour, concurrent challenging behaviours and the determinants of inappropriate sexual behaviour among patients with acquired brain injury ≤65 years of age in Dutch nursing homes. Design: Cross‐sectional, observational study in acquired brain injury special care units spreads throughout the country. Methods: Nursing homes were recruited through the national expertise network for patients with severe acquired brain injury, regional brain injury teams and by searching the Internet. Patient characteristics were collected through digital questionnaires. Inappropriate sexual behaviour was assessed with the St. Andrews Sexual Behaviour Assessment, concurrent challenging behaviours with the NeuroPsychiatric Inventory‐Nursing Home Version and the Cohen‐Mansfield Agitation Inventory, cognition with the Mini‐Mental State Examination and activities of daily living with the Disability Rating Scale. Psychotropic drug use was retrieved from the electronic prescription system. Associations between determinants and inappropriate sexual behaviour were examined using multilevel multivariate linear regression model analyses. Data collection started in June 2017 and ended in April 2019. Results: Of the 118 included patients, 38.1% had one or more inappropriate sexual behaviours. Verbal comments (30.1%) and non‐contact behaviour (24.8%) were the most prevalent types of inappropriate sexual behaviour. Less severe behaviours were more common than more severe behaviours. The most frequent concurrent challenging behaviours were agitation, aggression and hyperactivity. Physical aggression was associated with more inappropriate sexual behaviour. Being married and pain were associated with less inappropriate sexual behaviour. Conclusion: Inappropriate sexual behaviour is prevalent in patients with acquired brain injury ≤65 years of age residing in nursing homes. Impact: Inappropriate sexual behaviour may have impact not only on the patients themselves but also on nursing staff. Insight into the magnitude, severity, course and concurrent challenging behaviours, sexuality and quality of life could give direction to the kind of interventions and education that is needed. The ultimate goal is to develop appropriate care for this vulnerable group of patients, specifically psychosocial interventions and appropriate use of psychotropic drugs. [ABSTRACT FROM AUTHOR]

From the perspective of the nursing home (NH) practitioners, to gain understanding of (1) whether challenging behavior in NH residents changed during the COVID-19 measures, (2) whether the practitioners' involvement in the treatment of challenging behavior changed, (3) what can be learned from the experience of NH staff. A mixed methods study with a survey in 323 NH practitioners (psychologists, elderly care physicians, nurse practitioners) in the Netherlands, and in-depth interviews in 16 NH practitioners. Nonparametric analyses were used to compare estimated proportions of residents with increased and with decreased challenging behavior. Content analyses were conducted for open-ended questions and in-depth interviews. Participants reported changes in challenging behavior with slightly higher proportions for increased (Q1/Mdn/Q3: 12.5%, 21.7%, 30.8%) than for decreased (8.7%, 14.8%, 27.8%, Z = –2.35, p =.019) challenging behavior. Half of the participants reported that their work load increased and work satisfaction worsened during the measures. Different strategies were described to respond to the effects of COVID-19 measures, such as video calls, providing special areas for residents to meet their loved ones, adjusting activities, and reducing the exposure to negative news. Because COVID-19 measures resulted in both increased and decreased challenging behavior in NH residents, it is important to monitor for their potential long lasting effects. Increased work load and worsened work satisfaction of the NH staff, together with the changes in type of challenging behavior, indicate that the harmful effects of the anti-pandemic measures should be taken seriously. [ABSTRACT FROM AUTHOR]

Establishing the prevalence and determinants of neuropsychiatric symptoms (NPS) in patients with acquired brain injury (ABI) in nursing homes. Cross-sectional, observational study. Patients 18-65 years old with ABI in special care units in Dutch nursing homes. Nursing homes were recruited through the national expertise network for patients with severe ABI, regional brain injury teams, and by searching the Internet. Patient characteristics were collected through digital questionnaires. NPS were assessed with the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) and the Cohen-Mansfield Agitation Inventory (CMAI), cognition with the Mini-Mental State Examination, and activities of daily living with the Disability Rating Scale. Psychotropic drug use (PDU) was retrieved from the electronic prescription system. Individual NPS were clustered. Associations between determinants and NPS were examined using multilevel multivariate linear regression models. In a population of 118 patients from 12 nursing homes, 73.7% had 1 or more clinically relevant NPS and 81.3% 1 or more agitated behaviors. The most common NPS were agitation, in particular aberrant motor behavior (24.6%), repetitious sentences/questions (35.5%), and constant requests for attention (34.6%), verbal (33.6%) and physical (50.5%) aggression, and irritability (28.0%). Male patients were more likely to display hyperactivity. Being married was associated with less verbally agitated behavior and pain was associated with a higher CMAI total score. PDU increased the likelihood of a higher NPI-NH total score. NPS are common in patients with ABI ≤65 years of age residing in nursing homes. This is a first step to fill in the knowledge gap concerning NPS in this population. An increasing number of patients with severe ABI may survive the acute phase and will reside many years in nursing homes. It is important to shed more light on these NPS, with regard to course, magnitude, and severity, to ultimately develop appropriate care for this vulnerable group of patients. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the cost-consequences of an intervention for the management of neuropsychiatric symptoms in nursing home residents with young-onset dementia.Methods: A stepped wedge design was used. The intervention consisted of an educational program and a multidisciplinary care program and was implemented in 13 nursing homes from September 2015 to March 2017. Costs' outcomes included the time investment of the elderly care physician and health care psychologists regarding the management of neuropsychiatric symptoms, residents' psychotropic drug use, nursing staff absenteeism, and costs of the educational program. Composite cost measure contained the sum of costs of staff absenteeism, costs on psychotropic drugs, and costs of the educational program. Costs of time investment were investigated by comparing means. Costs of psychotropic drug use were analyzed with mixed models at resident level and as part of the composite cost measure on unit level. Staff absenteeism was also analyzed at unit level.Results: Compared with care as usual, the mean costs of time invested decreased with €36.79 for the elderly care physician but increased with €46.05 for the health care psychologist in the intervention condition. Mixed model analysis showed no effect of the intervention compared with care as usual on the costs of psychotropic drug use, staff absenteeism, and the composite cost measure. The costs of the educational program were on average €174.13 per resident.Conclusion: The intervention did not result in increased costs compared with care as usual. Other aspects, such as the lack of a structured working method, should be taken into account when considering implementation of the intervention. [ABSTRACT FROM AUTHOR]

Aim: Establishing the prevalence of neuropsychiatric symptoms (NPS), quality of life and psychotropic drug use in people aged ≤65 years with acquired brain injury in nursing homes. Design: Cross‐sectional, observational study among patients aged 18–≤65 years with acquired brain injury admitted to special care units in Dutch nursing homes. Methods: According to the Committee on Research Involving Human Subjects in January 2017 this study did not require ethics approval. Nursing homes will be recruited through the national acquired brain injury expertise network for patients with severe brain injury, the regional brain injury teams and by searching the internet. Patient characteristics will be collected through digital questionnaires. Neuropsychiatric symptoms will be assessed with the NeuroPsychiatric Inventory‐Nursing Home version, the Cohen–Mansfield Agitation Inventory and the St. Andrews Sexual Behaviour Assessment; cognition with the Mini‐Mental State Examination, quality of life with the Quality of Life after Brain Injury Overall Scale and activities of daily living with the Disability Rating Scale. Medication will be retrieved from the electronic prescription system. Data collection commenced in 2017 and will be followed by data analysis in 2019. Reporting will be completed in 2020. Discussion: Little is known about NPS among patients with acquired brain injury in nursing homes. In patients up to the age of 65 years, only six studies were found on prevalence rates of NPS. Impact: Patients with severe acquired brain injury experience lifelong consequences, that have a high impact on them and their environment. Although there is increasing attention for the survival of this vulnerable group of patients, it is also important to enlarge awareness on long‐term consequences, specifically the NPS, quality of life and psychotropic drug use in acquired brain injury. Insight into the magnitude of these issues is necessary to achieve appropriate care for these patients. [ABSTRACT FROM AUTHOR]

Nursing home physicians face heavy workloads, because of the aging population and rising number of older adults with one or more chronic diseases. Skill mix change, in which professionals perform tasks previously reserved for physicians independently or under supervision, could be an answer to this challenge. The aim of this study was to describe how skill mix change in nursing homes is organized from four monodisciplinary perspectives and the interdisciplinary perspective, what influences it, and what its effects are. The study focused particularly on skill mix change through the substitution of nurse practitioners, physician assistants, or registered nurses for nursing home physicians. Five focus group interviews were conducted in the Netherlands. Variation in tasks and responsibilities was found. Despite this variation, stakeholders reported increased quality of health care, patient centeredness, and support for care teams. A clear vision on skill mix change, acceptance of nurse practitioners, physician assistants, and registered nurses, and a reduction of legal insecurity are needed that might maximize the added value of nurse practitioners, physician assistants, and registered nurses. [ABSTRACT FROM AUTHOR]

Neuropsychiatric symptoms are common in nursing home residents with young-onset dementia and burdensome for nursing staff. It is known that neuropsychiatric symptoms are associated with burn-out complaints and low job satisfaction. An intervention aimed at decreasing neuropsychiatric symptoms in nursing home residents with young-onset dementia might also result in less burnout complaints and job demands and improve job satisfaction in nursing staff. The aim was to evaluate the effect of the intervention on nursing staff burnout, job satisfaction and job demands. Cluster randomised controlled trial using a stepped wedge design with a total duration of 18 months, with four assessments. Thirteen young-onset dementia special care units across the Netherlands were, by means of random allocation software, assigned to three groups crossing over at different time points. All nursing staff, in total 391, were invited to participate. 305 nursing staff participated during the course of the study of whom 71 participated in all assessments. An educational program followed by a structured multidisciplinary care program aimed at the management of neuropsychiatric symptoms. The care program consists of evaluation of psychotropic drug prescription followed by detection, analysis, treatment and evaluation of treatment of neuropsychiatric symptoms. Emotional exhaustion, depersonalisation and personal accomplishment were assessed with the Utrecht Burnout Scale. Job satisfaction and job demands were assessed with subscales of the Leiden Quality of Work Questionnaire. The baseline burnout risk on emotional exhaustion and personal accomplishment was average, and low on depersonalisation. The mean scores for job satisfaction were above average and for job demands average. Linear mixed models showed that the intervention had no effect on emotional exhaustion (estimated effect −0.04, 95% confidence interval −1.25 to 1.16), depersonalisation (estimated effect 0.24, 95% confidence interval −0.26 to 0.74), personal accomplishment (estimated effect −0.82, 95% confidence interval −1.86 to 0.22) job satisfaction (estimated effect −0.40, 95% confidence interval −0.98 to 0.17) and job demands (estimated effect −0.04, 95% confidence interval −0.57 to 0.49). A significant difference was found between registered nurses and other nursing staff on emotional exhaustion and job satisfaction. Compared to other staff members, registered nurses' emotional exhaustion scores slightly increased while job satisfaction slightly decreased when using the intervention. The intervention was not effective on three dimensions of burnout, job satisfaction and job demands. Staff scored positive on the outcomes of interest before implementation of the intervention, leaving little opportunity for improvement. [ABSTRACT FROM AUTHOR]

Objectives: Neuropsychiatric symptoms (NPSs) in dementia patients in nursing homes are common and often treated with psychotropic drugs. Thus far, studies on psychotropic drug use (PDU) mainly focused on elderly patients with dementia. It is important to know the prevalence and correlates of PDU in patients with young‐onset dementia (YOD) to optimize NPS treatment and reduce excess PDU in this group. Design The Behavior and Evolution in Young‐Onset Dementia (BEYOnD) study is a cross‐sectional study in 230 residents with YOD in eight nursing homes providing specialized YOD care. PDU was registered from medical charts. The influence of age, gender, severity, and type of dementia, NPS, and agitation on PDU was analyzed. Results: Eighty‐seven percent of the residents used psychotropic drugs, and 47% used two or more psychotropic drugs. No significant associations with age, gender, dementia subtype, and dementia severity were found. Depressive symptoms showed an association with the use of antidepressants, nighttime behavior with use of hypnotics, and verbal agitation with antipsychotics. Apathy was strongly associated with lower PDU. Conclusions: Nursing home patients with YOD have a high prevalence of PDU. The association with NPS raises questions of efficacy of these drugs in managing NPS. Patients with apathy had a lower chance of using psychotropics. More research on indications and effects of psychotropic drugs is needed, as well as on (nonpharmacological) alternatives for managing challenging behavior in YOD. [ABSTRACT FROM AUTHOR]

Objective: The aims of the current study are (1) to explore the differences in neuropsychiatric symptoms (NPS) between young-onset dementia (YOD) and late-onset dementia (LOD), and (2) to investigate whether the possible differences can be attributed to differences in dementia subtype, gender, psychotropic drug use (PDU), or dementia severity. Method: Three hundred and eighty-six nursing home (NH) residents with YOD and 350 with LOD were included. Multilevel modeling was used to compare NPS between the groups. Furthermore, dementia subtype, gender, PDU, and dementia severity were added to the crude multilevel models to investigate whether the possible differences in NPS could be attributed to these characteristics. Results: Higher levels of apathy were found in NH residents with YOD. After the characteristics were added to the models, also lower levels of verbally agitated behaviors were found in YOD. Conclusion: We recommend that special attention be paid to interventions targeting apathy in YOD. Although no differences in other NPS were found, the PDU rates were higher in YOD, suggesting that the threshold for the use of PDU in the management of NPS is lower. This underscores the need for appropriate attention to non-pharmacological interventions for the management of NPS in YOD. [ABSTRACT FROM AUTHOR]

Purpose: To explore the association between apathy and health-related quality of life (HRQoL) from resident and proxy perspectives and whether cognition and depression moderate this relationship.Methods: Secondary analyses with baseline data from a cluster randomized trial on the effects of a care program for depression in Nursing Homes (NHs) were conducted. For HRQoL, the Visual Analogue Scale (VAS) and the Dutch version of the European Quality of Life (EQ-5D) were administered to 521 NH residents, and to professional caregivers reporting from the perspective of the NH resident (Resident-Proxy) and from their own perspective (Proxy-Proxy). Utility scores (U) were calculated for the three perspectives. Apathy, depression, and cognition were measured using the 10-item Apathy Evaluation Scale, the Cornell Scale for Depression in Dementia, and the standardized Mini-Mental State Examination, respectively.Results: Mixed models adjusted for clustering within NH units revealed that apathy was negatively associated with HRQoL both from the Resident-Proxy perspective (EQ-5D VAS: estimated effect, - 0.31, P < 0.001; EQ-5D Utility: - 0.30, P < 0.001) and from the Proxy-Proxy perspective (VAS: - 0.29, P < 0.001; U: - 0.03, P < 0.001), but not from the Resident-Resident perspective (VAS: - 0.05, P = 0.423; Utility: - 0.08, P = 0.161). Controlling for depression and cognition and their interaction terms with apathy did not change the results.Conclusion: Apathy is negatively associated with NH resident HRQoL as reported by proxies. Depression and cognitive functioning do not moderate this association. NH residents do not self-report a relationship between apathy and HRQoL. More research is needed to understand caregiver and NH resident attitudes and underlying assumptions regarding apathy and HRQoL. [ABSTRACT FROM AUTHOR]

Objectives: To determine psychotropic drug prescription rates in nursing home residents with dementia and to identify associations with the so far understudied psychosocial non-resident-related factors. Method: A cross-sectional, observational, exploratory design as part of PROPER I (PRescription Optimization of Psychotropic drugs in Elderly nuRsing home patients with dementia). Participants were 559 nursing home residents with dementia, 25 physicians, and 112 nurses in the Netherlands. Psychotropic drug prescription, non-resident-related and known resident-related variables were measured to operationalize the themes of our previous qualitative analysis. Results: Fifty-six percent of residents were prescribed any psychotropic drug, 25% antipsychotics, 29% antidepressants, 15% anxiolytics, and 13% hypnotics, with large differences between the units. Multivariate multilevel regression analyses revealed that antipsychotic prescription was less likely with higher physicians’ availability (odds ratio 0.96, 95% confidence interval 0.93-1.00) and that antidepressant prescription was more likely with higher satisfaction of nurses on resident contact (odds ratio 1.50, 95% confidence interval 1.00-2.25). Resident-related factors explained 6%-15% of the variance, resident- and non-resident-related factors together 8%-17%. Conclusion: Prescription rates for antipsychotics are similar compared to other countries, and relatively low for antidepressants, anxiolytics, and hypnotics. Our findings indicate that improvement of prescribing could provisionally best be targeted at resident-related factors. [ABSTRACT FROM AUTHOR]

Objectives A process evaluation was performed for an intervention aimed at improvement of the management of neuropsychiatric symptoms in young-onset dementia. Data about sample quality and intervention quality was evaluated to better understand internal and external validity. In addition, data about the implementation strategy and factors affecting implementation were evaluated to improve further implementation of the intervention. Design A model proposed by Leontjevas and colleagues consisting of first-order (validity) and second-order (implementation) data was used. Setting and Participants Care units delivering specialized treatment and support for residents with young-onset dementia. Measures A description of the recruitment, randomization procedure, and intervention reach was carried out to determine sample quality. To determine intervention quality, data on satisfaction, relevance, feasibility, and fidelity were collected through a questionnaire and reports logged on the server of the web-based intervention. A description of the implementation strategy was provided. Barriers and facilitators for implementation were collected by a questionnaire and analyzed by deductive content analysis. Results Care units varied in size and were recruited from different geographical regions in the Netherlands. The informed consent rate of the residents was 87.7%. The majority of the nursing home staff were satisfied with the intervention. However, parts of the intervention were perceived as less relevant for their own organization. The feasibility of the intervention was considered low. The fidelity differed between care units. The implementation strategy did not overcome all barriers. Factors affecting implementation covered 3 themes: organizational aspects, culture of the organization, and aspects of the intervention. Conclusions In general, our results showed sufficient internal and external validity, warranting further effect analyses. Adaptations to specific steps of the care program should be considered to increase feasibility and sustainability. In addition, integration of the care program into the electronic health records is expected to further improve implementation. [ABSTRACT FROM AUTHOR]

Objectives To determine the prognostic value of apathy for mortality in patients of somatic ( SC) and dementia special care ( DSC) nursing home ( NH) units. Design Longitudinal design, secondary analyses of a 2-year, cluster-randomized trial with six measurements, approximately 4 months in between. Setting SC and DSC-units of Dutch NHs. Participants NH-patients of seventeen SC-units (n = 342) and sixteen DCS-units (n = 371). Measurements Data were available for 713 NH-patients, 266 of whom died during the study. Apathy was assessed using the 10-item Apathy Evaluation Scale ( AES-10) and applied as categorical variable using known cut-off scores as well as dimensional variable. Additionally, depressive symptoms were assessed using the Cornell Scale for Depression in Dementia. Results Mixed effects cox models using the coxme package in R revealed a higher risk of mortality between two measurements, if apathy was present (hazard ratio ( HR) = 1.77; 95% confidence interval ( CI] = 1.35-2.31, P < .001). Results remained significant ( HR = 1.64; 95% CI = 1.23-2.19, P < .001) when controlled for depressive symptoms. DSC-units and SC-units did not differ ( P > .05) in the effect of apathy on mortality. Male gender ( HR = 1.67; 95% CI = 1.23-2.27, P < .001), and higher age in years ( HR = 1.06; 95% CI = 1.04-1.08, P < .001) were also predictors of mortality. Regarding apathy as a dimensional construct, one standard deviation increase of AES-10 scores was associated with a 62% increase of mortality risk ( HR = 1.62, 95% CI = 1.40-1.88, P < .001). Conclusions Apathy was associated with mortality over a 4-month period in NH patients, even when controlling for depression. These data suggest that screening and treatment strategies for apathy should be developed for this patient population. [ABSTRACT FROM AUTHOR]

Aims: The aims of this study are to (1) explore the determinants of quality of life (QoL) in nursing home residents with young-onset dementia (YOD), (2) investigate whether there are differences between dementia subtypes (Alzheimer dementia, vascular/mixed dementia, frontotemporal dementia, other) regarding these determinants, and (3) compare QoL profiles of YOD nursing home residents across dementia subtypes. Methods: This cross-sectional study included 207 nursing home residents. Multilevel modeling was used to determine the relationships between QoL and neuropsychiatric symptoms (NPS), dementia severity, psychotropic drug use (PDU), dementia subtype, age, and gender. Additional multilevel models were used to compare aspects of QoL between dementia subtypes. Results: Residents' QoL was negatively associated with advanced dementia, PDU, and NPS. In general, the relationships between the determinants and QoL were similar across the dementia subtypes. Aspects of QoL differed by dementia subtype. Residents with frontotemporal dementia showed less negative emotions, accepted more help and experienced better quality of relationships with professional caregivers, had a more positive self-image, felt more comfortable in the nursing home environment, and experienced lower quality of social relationships. Conclusions: Considering the high rates of NPS and PDU in YOD residents and their negative associations with QoL, we recommend emphasizing services to manage and reduce NPS and PDU in nursing home residents with YOD. Furthermore, our findings suggest accounting for differences in aspects of QoL by dementia subtype to address specific needs and thereby improve QoL. [ABSTRACT FROM AUTHOR]

Objective Young-onset dementia (YOD) is defined as dementia that develops before the age of 65. Neuropsychiatric symptoms (NPS) have important clinical consequences for patients and their family members. To date, knowledge about the prevalence and correlates of NPS in YOD is limited, but essential to establish specific tailored care for patients with YOD. The aim of this study was to explore the prevalence and correlates of NPS in nursing home residents with YOD. Design/Setting Cross-sectional cohort study in Dutch long-term care facilities providing specialized care for YOD. Participants Participants included 230 institutionalized patients with YOD. Measurements NPS were assessed using the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory-Nursing Home version (NPI-NH). The influence of gender, dementia severity, type of dementia, and disease awareness on clusters of relevant NPS was investigated using multivariate logistic regression analysis and subsequently corrected for the possible confounders of age, duration of institutionalization, and psychoactive medication use. Results Ninety percent of the nursing home residents with YOD showed 1 or more neuropsychiatric symptoms, 88% showed significant agitation, and 56% showed relevant apathy. No gender differences were found. Although physically aggressive behavior, non–physically aggressive behavior, and apathy were more common in patients with (very) severe cognitive decline (Global Deterioration Scale [GDS] stage 6–7), verbally agitated behavior was common in patients in all except the most severe stages of dementia (GDS 2–6). Apathy was more prevalent in alcohol-related dementia. Low levels of awareness were associated with more physically aggressive behavior and aberrant motor behavior. Conclusion The prevalence of NPS was high and was associated with the severity and type of dementia and disease awareness. Agitation and apathy are the most important symptoms to focus on in YOD. The high prevalence of NPS supports the idea of care delivery in special care units. Further research is needed on potentially influencing environmental correlates of NPS in YOD. [ABSTRACT FROM AUTHOR]

Background: People with dementia can benefit from a palliative care approach. Recommendations, such as those of the EAPC have been proposed to strengthen the provision of palliative care for this group of patients. Yet, it remains challenging for professionals to identify when a person with dementia is in need of palliative care. The objective of this study therefore was to explore when professionals in long-term care settings consider a person with dementia in need of palliative care. Methods: Teams with in total 84 professionals working in 13 long-term care settings from 6 countries (France, Germany, Italy, Norway, Poland and the Netherlands) received a case-vignette concerning a person with dementia recently admitted to a nursing home. Teams were asked to discuss when they considered people with dementia eligible for palliative care. The constant comparative method was used to analyse their answers. Results: Three different time points in the disease trajectory when people with dementia were considered to be eligible for palliative care were extracted: (1) early in the disease trajectory; (2) when signs and symptoms of advanced dementia are present; and (3) from the time point that curative treatment of co-morbidities is futile. Yet, none of these time points was uniformly considered by the professional teams across Europe. In some cases, professionals working in the same nursing home didn't even reach consensus when considering persons with dementia eligible for palliative care. Conclusion: The results of the study identified that professionals across Europe have different opinions regarding the time point when to consider a person with dementia in need of palliative care. [ABSTRACT FROM AUTHOR]

Background: Nursing home patients with dementia use psychotropic drugs longer and more frequently than recommended by guidelines implying psychotropic drugs are not always prescribed appropriately. These drugs can have many side effects and effectiveness is limited. Psychotropic drug use between nursing home units varies and is not solely related to the severity of neuropsychiatric symptoms. There is growing evidence indicating that psychotropic drug use is associated with environmental factors, suggesting that the prescription of psychotropic drugs is not only related to (objective) patient factors. However, other factors related to the patient, elderly care physician, nurse and the physical environment are only partially identified. Using a mixed method of qualitative and quantitative research, this study aims to understand the nature of psychotropic drug use and its underlying factors by identifying: 1) frequency and appropriateness of psychotropic drug use for neuropsychiatric symptoms in nursing home patients with dementia, 2) factors associated with (appropriateness of) psychotropic drug use. Methods: A cross-sectional mixed methods study. For the quantitative study, patients with dementia (n = 540), nursing staff and elderly care physicians of 36 Dementia Special Care Units of 12 nursing homes throughout the Netherlands will be recruited. Six nursing homes with high average rates and six with low average rates of psychotropic drug use, based on a national survey about frequency of psychotropic drug use on units, will be included. Psychotropic drugs include antipsychotics, anxiolytics, hypnotics, antidepressants, anticonvulsants and anti-dementia drugs. Appropriateness will be measured by an instrument based on the Medication Appropriateness Index and current guidelines for treatment of neuropsychiatric symptoms. Factor associated to psychotropic drug use, related to the patient, elderly care physician, nurse and physical environment, will be explored using multilevel regression analyses. For the qualitative study, in depth interviews with staff will be held and analyzed to identify and explore other unknown factors. Discussion: This study will provide insight into factors that are associated with the frequency and appropriateness of psychotropic drug use for neuropsychiatric symptoms. Understanding psychotropic drug use and its associations may contribute to better dementia care. [ABSTRACT FROM AUTHOR]

Objectives To determine the prevalence of nonmotor symptoms ( NMS) in nursing home ( NH) residents with Parkinson's disease ( PD) and to establish the association with quality of life. Design Cross-sectional. Setting Nursing homes in the southeast of the Netherlands. Participants Nursing home residents with PD and a Mini- Mental State Examination score of 18 or greater (N = 73; mean age 78.7, disease duration 10 years, mainly Hoehn and Yahr Stages 4 (38%) and 5 (49%)) underwent detailed examination to determine the prevalence of NMS. Measurements Validated instruments for PD-related NMS were used to examine the NH residents with PD. The overall burden of NMS, and autonomic problems in particular, were measured using the Non- Motor Symptoms Scale ( NMSS). Depression, neuropsychiatric symptoms, sleep problems, cognitive dysfunction, and motor impairments were focused on in further detail using established clinimetric tests. Linear regression analysis was used to examine the relationship between these symptoms and quality of life, which was measured using the Parkinson's Disease Questionnaire ( PDQ-8). Results The NMSS revealed a mean of nearly 13 different NMS per resident. Autonomic problems (constipation, urinary urgency) were particularly prevalent (48-75% of residents). Depressive symptoms were present in 45%. The most prevalent neuropsychiatric symptoms other than depression were irritability and apathy. The most common sleep problems were overall poor nighttime sleep quality, daytime sleepiness, and nocturia. Cognitive problems were highly prevalent, and 77% of the residents met the criteria for PD-related dementia. High scores were also obtained for motor impairments. Mean PDQ-8 score was high, indicating poor quality of life. Poor quality of life was most strongly associated with the prevalence and severity of overall NMS burden (coefficient of determination = 0.45). Conclusion Nonmotor symptoms were highly prevalent in NH residents with PD. Quality of life was poor, largely because of NMS. Because many NMS are potentially treatable, diagnosis and treatment of these severely affected individuals deserve more attention. [ABSTRACT FROM AUTHOR]

Objective This study aimed to establish whether antipsychotic (AP) use in patients with dementia negatively affects quality of life (QoL) independent of neuropsychiatric symptoms (NPS). Method We tested 290 patients with dementia living in nine nursing homes throughout the Netherlands in a longitudinal study. The measurements were repeated every 6 months over 2 years. We studied the change in NPS and AP use and their effect on QoL over time in two separate generalized estimating equations. We assessed QoL and NPS using the Qualidem questionnaire and the Neuropsychiatric Inventory-Nursing Home Version (NPI-NH), respectively. Results Antipsychotic prescriptions did not significantly change participant QoL, whereas NPI-NH total score changes consistently predicted changes in QoL. According to the Qualidem, the development of QoL in patients who chronically used APs did not differ from AP-free patients, except on the restless tense behavior subscale. AP-free patients' 'restless tense behavior' improved compared with patients who chronically used APs, who showed a slight deterioration in these symptoms; however, this effect did not significantly influence total QoL. Conclusion Antipsychotic use does not necessarily have detrimental effects on the QoL of patients with dementia; rather, NPS consistently and negatively affects QoL. The use of APs to treat NPS is justified when used carefully (i.e., their benefits and side effects should be monitored). Copyright © 2012 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives To examine the clinical characteristics, motor impairments, and drug treatments of nursing home residents with Parkinson's disease ( PD). Design Cross-sectional study. Setting Nursing homes in the southeast of the Netherlands. Participants Nursing home residents with PD and a Mini- Mental State Examination score of 18 or greater seen by a physician with experience in movement disorders. Measurements Participant characteristics, motor function, and dopaminergic medications were assessed. The Short Parkinson's Evaluation Scale/ SCales for Outcomes in Parkinson's disease ( SPES- SCOPA) was used to assess motor impairments and disabilities. Results Seventy-three nursing home residents with PD (mean age 78.7; 45% male; mean disease duration 10.1 years; Hoehn and Yahr 4 (38%) and 5 (49%)) were included. Most residents were severely disabled, 49% being wheelchair bound. According to the SPES- SCOPA, 44% of residents were 'off' (in a motor state in which they are slow and stiff) most of the time. Dyskinesias were encountered infrequently. Most residents were mainly treated with levodopa monotherapy, and daily doses varied widely (20-1,600 mg, mean 673 mg); 25% of residents were treated with less than 400 mg levodopa daily, and 8% received no levodopa at all. The movement disorders specialist considered 32 residents to be possibly undertreated. Conclusion These findings show that PD in nursing home residents is characterized by severe motor impairment and a high proportion of daily 'off' time, which underscores the need for better management of PD in nursing homes, for example within specialized institutions or with periodic consultations by a movement disorders expert. [ABSTRACT FROM AUTHOR]

Objective This study aims to test the accuracy of the Nijmegen Observer-Rated Depression (NORD) scale, a new short scale for screening of depression in nursing home (NH) residents with and without dementia. Methods This cross-sectional study with 103 residents with dementia ( N = 19 depressed) and 72 residents without dementia ( N = 10 depressed) was undertaken in 13 Dutch NH units. An elderly care physician and a psychologist of each unit assessed residents for the presence of clinical depression. Primary professional caregivers administered the NORD scale. Results Five of the six proposed items showed acceptable performance in screening for depression. Receiver operating characteristic analyses revealed significant areas under the empirical curve (AUC) for the 5-item NORD scale in the total sample ( AUC = 0.83, p < 0.001), as well as in residents with dementia ( AUC = 0.84, p < 0.001) and without dementia ( AUC = 0.84, p < 0.001). The cutoff score of >1 showed the highest sum of sensitivity (100) and specificity (69) in non-dementia and >2 the highest sum of sensitivity (79) and specificity (77) in dementia. The cutoff score of >1 showed the lowest negative likelihood ratio of 0.0 in non-dementia and of 0.2 in dementia. The highest positive likelihood ratios were found for the cutoff of >2 in non-dementia (3.4) and for >4 in dementia (26.5). Conclusion The 5-item NORD scale showed acceptable accuracy comparable with those of more extensive scales in other studies. It is easy and quick to administer and can be used for screening of depression in NH residents with or without dementia. Copyright © 2011 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Abstract: Background: A multidisciplinary, evidence-based care program to improve the management of depression in nursing home residents was implemented and tested using a stepped-wedge design in 23 nursing homes (NHs): “Act in case of Depression” (AiD). Objective: Before effect analyses, to evaluate AiD process data on sampling quality (recruitment and randomization, reach) and intervention quality (relevance and feasibility, extent to which AiD was performed), which can be used for understanding internal and external validity. In this article, a model is presented that divides process evaluation data into first- and second-order process data. Methods: Qualitative and quantitative data based on personal files of residents, interviews of nursing home professionals, and a research database were analyzed according to the following process evaluation components: sampling quality and intervention quality. Setting: Nursing home. Results: The pattern of residents’ informed consent rates differed for dementia special care units and somatic units during the study. The nursing home staff was satisfied with the AiD program and reported that the program was feasible and relevant. With the exception of the first screening step (nursing staff members using a short observer-based depression scale), AiD components were not performed fully by NH staff as prescribed in the AiD protocol. Conclusion: Although NH staff found the program relevant and feasible and was satisfied with the program content, individual AiD components may have different feasibility. The results on sampling quality implied that statistical analyses of AiD effectiveness should account for the type of unit, whereas the findings on intervention quality implied that, next to the type of unit, analyses should account for the extent to which individual AiD program components were performed. In general, our first-order process data evaluation confirmed internal and external validity of the AiD trial, and this evaluation enabled further statistical fine tuning. The importance of evaluating the first-order process data before executing statistical effect analyses is thus underlined. [Copyright &y& Elsevier]

Objective To investigate the prevalence and course of neuropsychiatric symptoms (NPS) in geriatric patients admitted to skilled nursing facilities (SNFs) for rehabilitation after stroke. Methods This was a longitudinal multicenter study within 15 SNFs in the Netherlands. NPS were assessed in 145 patients with stroke through the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) with measurements on admission and at discharge. The prevalence and course of NPS were described in terms of cumulative prevalence (symptoms either on admission or at discharge), conversion (only symptoms at discharge), remission (only symptoms on admission), and persistence (symptoms both on admission and at discharge) for patients who were discharged to an independent living situation within one year after admission and patients who had to stay in the SNF for long term care. Results Eighty percent had a first-ever stroke and 74% could be successfully discharged. Overall, the most common NPS were depression (33%), eating changes (18%), night-time disturbances (19%), anxiety (15%), irritability (12%), and disinhibition (12%). One year after admission, the patients who were still in the SNF showed significantly more hallucinations ( p = 0.016), delusions ( p = 0.016), agitation ( p = 0.004), depression ( p = 0.000), disinhibition ( p = 0.004), irritability ( p = 0.018), and night-time disturbances ( p = 0.001) than those who had been discharged. Discussion The overall prevalence of NPS in this study was lower than reported by other studies in different settings. There was a high prevalence of NPS in patients that could not be successfully discharged. Conclusions The findings suggest that NPS should be optimally treated to improve outcome of rehabilitation. Copyright © 2011 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To study the practice of continuous palliative sedation (CPS) by Dutch nursing home physicians in 2007. DESIGN: A structured retrospective questionnaire. SETTING: Nationwide nursing home physician study in the Netherlands. PARTICIPANTS: One thousand two hundred fifty-four nursing home physicians received a questionnaire concerning their last case of CPS in 2007; 54% (n=675) responded. MEASUREMENTS: Characteristics of CPS and requests for euthanasia were measured. RESULTS: Three hundred sixteen patients were described. The majority had cancer or dementia. The most-reported refractory symptoms were pain (52%), anxiety (44%), exhaustion (44%), dyspnea (40%), delirium (24%), loss of dignity (18%), and existential distress (16%). In 98% of cases, CPS was aimed at symptom relief. Of patients with cancer, 17% had previously requested euthanasia. The mean starting dose of midazolam was 31 mg every 24 hours (range 0–240 mg/24 h), and the mean end dose was 48 mg every 24 hours (range 0–480 mg/24 h). CONCLUSION: In addition to physical symptoms, anxiety, exhaustion, loss of dignity, and existential distress are often mentioned as refractory symptoms in the decision to start CPS by nursing home physicians. Furthermore, close to one in five patients with cancer had made a previous request for euthanasia. The dosage range of midazolam in this study fits the recommendations of the Dutch national guideline on palliative sedation, although international studies show smaller dosage ranges. Finally, prospective research about the acceptability and assessment of nonphysical symptoms as indications for CPS is recommended. [ABSTRACT FROM AUTHOR]

Objective The aim of the study was to estimate the influence of environmental correlates of neuropsychiatric symptoms in nursing home patients with dementia. Methods 1289 patients in 56 Dementia Special Care Units (SCUs) in the Netherlands were assessed using the Neuropsychiatric Inventory–Nursing Home version (NPI–NH) and the Cohen-Mansfield Agitation Inventory (CMAI). Potential correlates of the neuropsychiatric symptoms studied were gender and age of the patient, dementia severity, psychoactive medication use and environmental correlates such as the number of patients per unit or per living room, staff size/patient ratio, time spent on care activities and presence of a walking circuit. Multilevel logistic regression analysis was used to estimate the relative contribution of the different factors in explaining neuropsychiatric symptoms variability. Results The prevalence of neuropsychiatric symptoms differed between SCUs, also after correcting for patient factors. Patient-related factors explained 7–21% of the total variance of neuropsychiatric symptoms. Intra Class Correlation (the correlation of symptoms of patients within SCUs) ranged from 0.039 (psychosis) to 0.163 (apathy). The variance in SCU symptom prevalence (variance between SCUs) accounted for 3.5–14.8% of the total variance in neuropsychiatric symptoms. In SCUs of which the staff spent more time on care activities did the patients show lower levels of apathy. Other environmental correlates did not predict neuropsychiatric symptoms. Conclusion The substantial variation of prevalence rates between SCUs in combination with the clustering of symptoms within SCUs is strong evidence for the environmental contribution to neuropsychiatric symptoms and the multifactorial nature of behaviour in dementia. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Introduction The aim of the study was to assess the influence of dementia severity and gender on neuropsychiatric symptoms in demented nursing home patients. Methods Neuropsychiatric symptoms were assessed in a large sample of 1319 Dutch nursing home patients using the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory–Nursing Home version (NPI-NH). The influence of gender and severity of cognitive decline, assessed with the Global Deterioration Scale (GDS), was investigated using logistic regression analysis and subsequently corrected for possible confounders, such as age, duration of institutionalization and psychoactive medication use. Results While physically aggressive behaviour was more common in patients with very severe cognitive deterioration (GDS stage 7), disinhibition, irritability, physically non-aggressive and verbally agitated behaviour were more common in patients in GDS stage 5 or 6. Physically aggressive behaviour was more common in men, whereas female patients demonstrated more verbally agitated behaviour. With respect to other neuropsychiatric symptoms, delusions and depression were also more common in patients in GDS stage 5 and 6, while prevalences of anxiety and apathy further increased in severely demented patients (GDS stage 7). Apathy was more prevalent in male patients, while depression and anxiety were more common in females. Conclusion In nursing home patients, neuropsychiatric symptoms were associated with the severity of dementia, with most symptoms occurring in patients showing (moderately) severe cognitive decline. Only physical aggression, anxiety and apathy were more common in patients with very severe cognitive decline. Dementia severity and gender were important predictors of neuropsychiatric symptoms in this patient cohort. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Challenging behavior is prevalent in people with dementia residing in nursing homes and places a high burden on the nursing staff of dementia special care units. This study evaluates an educational program for nursing staff for managing challenging behavior: The Educating Nursing Staff Effectively (TENSE) program. This program can be tailored to care organizations' wishes and needs and combines various learning styles. The aim of this cluster-randomized controlled trial was to examine the short-term (3 months) and long-term (9 months) effects of the TENSE training program on experienced stress, work contentment, and stress reactions at work in nursing staff working in dementia special care units. Cluster-randomized controlled trial. Nursing staff members of 18 dementia special care units within nine nursing homes from different Netherlands regions were randomized into an intervention (n = 168) or control (n = 129) group. The TENSE program consisted of a three-day training course and two follow-up sessions after three and six months, respectively. The primary outcome was stress experienced by nursing staff measured with the Utrecht Burnout Scale - C. Secondary outcomes were work contentment and stress reactions at work. Furthermore, process evaluation data on the reach of and compliance with the program and the program's feasibility and relevance were collected. Data were collected between November 2012 and November 2014. In general, the participants appreciated the quality and relevance of the TENSE training and evaluated the content of the training as beneficial. The TENSE training had no effect on the components of experienced stress, i.e., emotional exhaustion (p = 0.751), depersonalization (p = 0.701), and personal accomplishment (p = 0.182). Furthermore, no statistically significant effects of the intervention on work contentment and stress reactions at work were found. The TENSE training program did not have an effect on experienced stress, work contentment, nor stress reactions at work of nursing staff working in dementia special care units. In future studies, more focus on practicing new skills seems needed. Trial registration: NTR (Dutch Trial Registration) number NTR3620 [ABSTRACT FROM AUTHOR]

Objective To estimate the prevalence of neuropsychiatric symptoms of dementia patients in Dutch nursing homes. Methods Cross-sectional study in a large sample of 1322 demented patients living in 59 dementia special care units (SCUs) in The Netherlands. Symptoms were observed by licensed vocational nurses during regular care-giving in a 2-week observational period prior to assessment. Neuropsychiatric symptoms were assessed using the Neuropsychiatric Inventory- Nursing home version (NPI-NH; frequency X severity score ≥ 4) and the Cohen-Mansfield Agitation Inventory (CMAI; symptoms occurring at least once a week). Results More than 80% of these patients suffered from at least one clinically significant symptom, as defined with the NPI-NH frequency X severity score ≥ 4. Measured with the NPH-NH agitation/aggression, apathy and irritability were the most frequently observed behaviors, with prevalences of 30–35%. Using the CMAI, 85% of the patients showed at least one symptom of agitation, of which general restlessness was observed most frequently (44%). Other frequently observed symptoms with prevalence rates of 30% were cursing or verbal aggression, constant request for attention, negativism, repetitious sentences, mannerisms, pacing, and complaining. Physically aggressive symptoms such as hitting, kicking, biting occurred less often (less than 13%). Conclusions Prevalence rates of neuropsychiatric symptoms in Dutch nursing home patients with dementia residing in SCUs are high, especially agitation and apathy. Insight into the prevalence rates of individual symptoms in patients with dementia has important practical consequences for the accurate planning of staff allotment and stresses the need for patient oriented care. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

To explore the course of quality of life (QoL) and possible resident-related predictors associated with this course in institutionalized people with young-onset dementia (YOD). An observational longitudinal study. A total of 278 residents with YOD were recruited from 13 YOD special care units in the Netherlands. Secondary analyses were conducted with longitudinal data from the Behavior and Evolution in Young-ONset Dementia (BEYOND)-II study. QoL was assessed with proxy ratings, using the Quality of Life in Dementia (QUALIDEM) questionnaire at 4 assessment points over 18 months. Predictors included age, gender, dementia subtype, length of stay, dementia severity, neuropsychiatric symptoms, and psychotropic drug use at baseline. Multilevel modeling was used to adjust for the correlation of measurements within residents and clustering of residents within nursing homes. The total QUALIDEM score (range: 0-111) decreased over 18 months with a small change of 0.65 (95% confidence interval −1.27, −0.04) points per 6 months. An increase in several domains of QoL regarding care relationship, positive self-image, and feeling at home was seen over time, whereas a decline was observed in the subscales positive affect, social relations, and having something to do. Residents with higher levels of QoL and more advanced dementia at baseline showed a more progressive decline in QoL over time. Sensitivity analyses indicated a more progressive decline in QoL for residents who died during the follow-up. This study shows that although overall QoL in nursing home residents with YOD was relatively stable over 18 months, there were multidirectional changes in the QoL subscales that could be clinically relevant. Higher levels of QoL and more advanced stages of dementia at baseline predicted a more progressive decline in QoL over time. More longitudinal studies are needed to verify factors influencing QoL in YOD. [ABSTRACT FROM AUTHOR]

Extreme neuropsychiatric symptoms can be a heavy burden for nursing home (NH) residents, relatives, and caregivers. Sometimes, when extreme neuropsychiatric symptoms are considered refractory, continuous palliative sedation is administered. The aim of this study was to explore the trajectory leading to continuous palliative sedation and its administration in NH residents with dementia and refractory neuropsychiatric symptoms. A qualitative interview and explorative study was performed. Relatives, elderly care physicians, and other staff members involved with 3 NH residents with dementia and extreme refractory neuropsychiatric symptoms who received continuous palliative sedation were interviewed. These NH residents lived on dementia special care units of 3 NHs in the Netherlands. Consecutive sampling was used to select participants. Medical files were studied. Semistructured interviews were conducted. Transcriptions were analyzed with thematic analysis, including directed content analysis. Nine in-depth interviews with 13 participants were held. Analysis resulted in 6 main themes, with several subthemes reflecting phases of the continuous palliative sedation trajectory: (1) run-up, describing an unbearable struggle of the resident; (2) turning point, at which hope was lost; (3) considering continuous palliative sedation and administration of intermittent sedation; (4) decision to start continuous palliative sedation based on 1 decisive trigger; (5) administration of continuous palliative sedation with stakeholders experiencing relief; and (6) evaluation. The trajectory leading up to continuous palliative sedation in NH residents with dementia and extreme refractory neuropsychiatric symptoms was complex and burdensome, but the initiation led to relief and contentment for all those involved. This study highlights that continuous palliative sedation can be a valuable treatment option among these residents. A recommendation is to include external consultation in the decision process and to administer intermittent sedation as a preceding step when continuous palliative sedation is considered. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To compare the Neuropsychiatric Inventory apathy subscale (NPIa) with the abbreviated Apathy Evaluation Scale (AES-10) on discriminant validity and on their performance to distinguish residents as apathetic or nonapathetic. Design: Cross-sectional design. Setting: Nursing home. Participants: 100 residents of 4 dementia special care units (n = 58) and 3 somatic units (n = 42). Measurements: Primary professional caregivers were interviewed to score the AES-10 and NPIa. The elderly care physician and the psychologist of each unit examined residents for clinical apathy using diagnostic criteria. Results: The AES-10 and NPIa correlated moderately with each other (rs  = 0.62, P < .0001). The AES-10 correlated weakly (rs  = 0.27, P = .024) and the NPIa moderately (rs  = 0.46, P = .001) with the Cornell Scale for Depression in Dementia. Receiver operating characteristic analysis showed an area under the curve (AUC) of 0.72 (P < .01) for AES-10 and 0.67 (P < .05) for NPIa. The AES-10 produced higher sums of sensitivity and negative predictive value than the NPIa. Explorative analyses revealed that both instruments produced higher scores in dementia independently of having an apathy diagnosis, whereas AUCs were significant in nondementia (AES-10: AUC = 0.88, P < .001; NPIa: AUC = 0.77, P = .023), but not in dementia. Conclusion: Both the AES-10 and NPIa may be used to distinguish apathetic from nonapathetic residents in a heterogeneous sample with and without dementia, or in residents without dementia. The AES-10 may be preferable to the NPIa apathy subscale when ruling out or screening for apathy. The performance of the scales against diagnostic criteria of apathy in dementia need to be further examined. [Copyright &y& Elsevier]