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Background: Differential distributions of sociodemographic characteristics and cognitive impairment in responders and non-responders may result in a biased prevalence estimate of dementia based on responders only.Methods: Responders (n = 2191) to a cross-sectional, two-stage community study were compared with regard to sociodemographic characteristics and cognition with three subgroups of non-responders: (A) subjects who refused to participate (n = 369), (B) subjects who were too ill or who had died prior to the screening (n = 72) and (C) subjects who had moved out of the study region or were not traceable (n = 23). Prevalence estimates specific for age and housing situation in responders and physicians' ratings of cognitive impairment were used to estimate the prevalence of dementia among non-responders.Results: Group A differed from responders in age and housing situation, group B in age, housing and cognition, and group C only in age. Separate prevalence estimates of dementia based on age, housing and cognition yielded figures for group A between 4.9% and 7.2%, for group B between 13.1% and 19.1%, and for group C between 2.6% and 4.2%. Joined with the prevalence rate among responders (6.5%) the best possible point estimate of the prevalence of dementia in the target population lies between 6.4% and 6.9%, i.e. within the 95% confidence interval (CI) of the prevalence among responders (5.4-7.5%).Conclusions: Although in this study non-response had no important influence on the overall prevalence, the findings among the distinct non-response subgroups point to the importance of describing non-response sociodemographically as well as in terms of the study objective. The authors recommend that non-responders are categorized into distinct groups based on the reason for non-response. [ABSTRACT FROM AUTHOR]

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

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

Objective: Pain is a frequent long-term consequence of stroke, but its relation to emotional and social well-being is poorly studied in stroke populations. We aimed to identify the prevalence of substantial pain among institutionalized stroke patients and to explore its relation to emotional distress (ED) and low social engagement (SE)., Methods: In a cross-sectional design, we collected data of 274 chronic stroke patients in Dutch nursing homes. Observation lists were filled out in structured interviews with qualified nurse assistants who knew the residents well. Pain and SE were measured with the Resident Assessment Instrument for Long-term Care Facilities, and ED was measured with the Neuropsychiatric Inventory Questionnaire (NPIQ)., Results: Substantial pain was present in 28% of the residents, mostly located in the affected body side (68%). Multilevel regression analyses revealed that this pain was independently related to a 60% increase in NPIQ score (β 3.18 [1.84-4.53]) and to clinically relevant symptoms of delusions (odds ratio [OR] 8.45 [1.82-39.05]), agitation/aggression (OR 3.82 [1.76-8.29]), depression (OR 3.49 [1.75-6.98]), and anxiety (OR 2.32 [1.08-4.97]). Substantial pain was associated with low SE when adjusted for clinical covariates (OR 4.25 [1.72-10.53]), but only in residents with no/mild or severe cognitive impairment. This relation disappeared when additionally corrected for NPIQ score (OR 1.95 [0.71-5.39])., Conclusions: Pain is a serious and multidimensional problem among institutionalized stroke patients. It is related to increased ED, which in turn can be a pathway to low SE as an indicator of social vulnerability. Future research should reveal how pain management in nursing homes can be tailored to the needs of this patient group., (Copyright © 2014 John Wiley & Sons, Ltd.)

Objectives: Apathy is a frequent neuropsychiatric consequence of stroke. In the under-researched population of institutionalized stroke patients, we aimed to explore the prevalence of apathy, its clinical correlates, and the relation to the amount of stimulating activities in the nursing home (NH)., Design: A cross-sectional, observational study., Setting: Dutch NHs., Participants: 274 chronic stroke patients., Measurements: Data were collected through observation lists that were filled out in structured interviews with qualified nurse assistants who knew the residents well. The lists comprised the NH-version of the Apathy Evaluation Scale (AES10), the Barthel Index, the Neuropsychiatric Inventory Questionnaire, and sections of the Resident Assessment Instrument for Long-Term Care Facilities. Attending physicians and therapists provided additional information., Results: Apathy (AES10 score ≥30) was present in 28% of residents. Multilevel regression analyses revealed that this apathy was independently related to (moderate, severe) cognitive impairment (odds ratio [OR] 11.30 [95% confidence interval (CI): 4.96-25.74], OR 5.54 [95% CI: 2.48-12.40]), very severe ADL-dependency (OR 12.10 [95% CI: 1.35-108.66]), and being >12 hours per day in bed (OR 2.10 [95% CI: 1.07-4.13]). It was not related to depressive mood symptoms (OR 1.75 [95% CI: 0.91-3.37]). Only in residents aged less than 80 years were a higher amount of activities independently related to a lower AES10 score (-0.70 [95% CI: -1.18 to -0.20] points per four extra activities in a 4-week period)., Conclusions: Apathy is prevalent in largely one-quarter of institutionalized stroke patients, and that is most strongly related to cognitive impairment in this explorative study. We discuss the need for research on the relation with distinct dimensions of depression and fatigue as partly overlapping constructs, and on (individualized) stimulating activities as a possible intervention method., (Copyright © 2015 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Caring for people with dementia in dementia special care units is a demanding job. Challenging behaviour is one of the factors influencing the job satisfaction and burnout of care staff. A care programme for the challenging behaviour of nursing home residents with dementia might, next to diminishing the challenging behaviour of residents, improve job satisfaction and reduce the care staff's feelings of burnout., Objectives: To determine the effects of a care programme for the challenging behaviour of nursing home residents with dementia on the burnout, job satisfaction and job demands of care staff., Design: The care programme was implemented according to a stepped wedge design in which care units were randomly divided over five groups with different time points of starting with implementation., Setting: 17 Dutch dementia special care units., Participants: Care staff members of the 17 units., Intervention: The care programme consists of an education package and of various structured assessment tools that guide professionals through the multidisciplinary detection, analysis, treatment and evaluation of treatment of challenging behaviour., Methods: Burnout, job satisfaction and job demands were measured before implementation, halfway through the implementation process and after all the care units had implemented the care programme. Burnout was measured with the Dutch version of the Maslach burnout inventory (UBOS-C, three subscales); job satisfaction and job demands were measured with subscales of the Leiden Quality of Work Questionnaire. Mixed model analyses were used to determine effects. Care staff could not be blinded for the intervention., Results: Of the 1441 questionnaires, 645 were returned (response 45%, 318 control measurements, 327 intervention measurements) by 380 unique care staff members. Significant effects were found on job satisfaction (0.93, 95% CI 0.48-1.38). On the other outcomes, no significant changes in the scores were found., Conclusion: Positive effects of using the Grip on Challenging behaviour care programme were found on job satisfaction, without an increase in job demands., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: The Grip on Challenging Behavior care program for managing challenging behavior was implemented in the dementia special care units of 17 Dutch nursing homes. A process evaluation of the implementation of the care program was performed to determine the quality of the implementation and the lessons to be learned for future implementation., Methods: The care program was implemented according to a stepped wedge design. First-order data (data on recruitment, reach, relevance and feasibility) were used to determine the validity of the study, and second-order data (intervention quality and the barriers and facilitators for implementing the care program) were used to describe the implementation process. Two structured questionnaires were administered to care staff and key stakeholders and semi-structured interviews were held in the units., Results: University affiliated and non-affiliated nursing homes from different parts of the Netherlands participated. The resident participation rate was over 95% and the participation rate for the training sessions was 82%. Respondents considered the care program relevant and feasible. The degree of implementation was not optimal. The barriers and facilitators in implementing the care program could be divided into three categories: organizational aspects, culture on the unit and aspects of the care program itself., Conclusions: The recruitment, reach, relevance and feasibility are sufficient to allow for analysis and generalization of the effects of the care program, but the degree of implementation should be taken into account in further analysis. Future projects that involve implementation should consider the specific features of the organization and the cultural orientation of the unit to better adapt to specific needs., Trial Registration: The Netherlands National Trial register under number NTR2141 registered on 11 December 2009. Randomization took place in November 2010, and the first intervention group started using the intervention in February 2011.

Objectives: The Grip on Challenging Behavior care program was developed using the current guidelines and models on managing challenging behavior in dementia in nursing homes. It was hypothesized that the use of the care program would lead to a decrease in challenging behavior and in the prescription of psychoactive drugs without increase in use of restraints., Design: A randomized controlled trial was undertaken using a stepped-wedge design to implement the care program and to evaluate the effects. An assessment of challenging behavior and psychoactive medication was undertaken every 4 months on all participating units followed by the introduction of the care program in a group of 3 to 4 units. A total of 6 time assessments took place over 20 months., Setting: Seventeen dementia special care units of different nursing homes., Participants: A total of 659 residents of dementia special care units. All residents with dementia on the unit were included. Units were assigned by random allocation software to 1 of 5 groups with different starting points for the implementation of the care program., Intervention: A care program consisting of various assessment procedures and tools, which ensure a multidisciplinary approach and which structure the process of managing challenging behavior in dementia., Measurements: Challenging behavior was measured using the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory. Research assistants (blinded for intervention status of the unit) interviewed nurses on the units about challenging behavior. Data on psychoactive drugs and restraints were retrieved from resident charts., Results: A total of 2292 assessments took place involving 659 residents (1126 control measurements, 1166 intervention measurements). The group of residents who remained in the intervention condition compared with the group in the control condition differed significantly in the CMAI change scores between successive assessments [-2.4 CMAI points, 95% confidence interval (CI) -4.3 to -0.6]. No significant effects were found for the control-to-intervention group compared with the group who remained in the control group (0.0 CMAI points, 95% CI -2.3 to 2.4). Significant effects were found on 5 of the 12 Neuropsychiatric Inventory items and on the use of antipsychotics (odds ratio 0.54, 95% CI 0.37- 0.80) and antidepressants (odds ratio 0.65, 95% CI 0.44-0.94). No effect on use of restraints was observed., Conclusions: The Grip on Challenging behavior program was able to diminish some forms of challenging behavior and the use of psychoactive drugs., (Copyright © 2014 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To optimize care and interventions to improve care, and to reduce staff burden, it is important to have knowledge of the relation between individual neuropsychiatric symptoms and distress of care staff. We therefore explored the relation between frequency and severity of individual neuropsychiatric symptoms and distress of care staff., Design: This is an explorative study with a cross-sectional design., Participants and Setting: Care staff was interviewed regarding 432 residents of 17 nursing homes for people with dementia., Measurements: Behavioural problems were assessed using the Nursing Home version of the Neuropsychiatric Inventory (NPI-NH) questionnaire. The distress scale of the NPI-NH was used to determine the distress of care staff., Results: Agitation/aggression had the highest mean distress score and was also the most prevalent symptom. Disinhibition and irritability/lability also had high mean distress scores, whereas euphoria/elation, hallucinations and apathy had the lowest mean distress score. The symptom severity of each symptom strongly predicted the distress score, whereas the frequency of the symptoms was a less important factor., Conclusions: Although some of these findings are in accordance with studies among informal caregivers, there are also notable differences. Apathy caused little distress among care staff. Therefore, care staff might not feel the urgency to explore the causes of this symptom. The findings of this study emphasize the importance of supporting care staff in the management of behavioural problems, especially aggression and apathy., (Copyright © 2013 John Wiley & Sons, Ltd.)

Background: Current guidelines and theories on the origin of challenging behaviour in dementia indicate that a structured multidisciplinary approach to its management is necessary. In the Grip on Challenging Behaviour study, a care programme was developed to improve the management of challenging behaviour., Method: In developing the care programme, the overlapping parts of dementia care guidelines were supplemented with discipline-specific parts. Three meetings with experts were arranged to further develop the structure of the care programme and to ensure a good fit with practice., Results: The care programme consists of four steps: detection, analysis, treatment, and evaluation. For each step, forms were developed to guide and structure the process and assign responsibilities for each discipline. As well as a description of the development and the content of the care programme, this paper presents two case studies in which the programme was used., Conclusion: The Grip on Challenging Behaviour care programme provides a way for dementia special care units to manage challenging behaviour in a structured way and with a multidisciplinary approach making use of their own resources.

Purpose: To identify factors in the early post-stroke period that have a predictive value for a poor outcome, defined as institutionalization or severe disability., Methods: MEDLINE, PSYCINFO, EMBASE and CINAHL were systematically searched for observational cohort studies in which adult and/or elderly stroke patients were assessed ≤ 1 month post-stroke and poor outcome was determined after a follow-up of ≥ 3 months., Results: Thirty three articles were selected from 4063 records, describing 27 independent cohort studies. There are rather consistent findings that greater age, a more severe stroke (measured through a clinical evaluation scale), the presence of urinary incontinence (with impaired awareness) and a larger stroke volume (measured through brain imaging techniques) predict poor stroke outcome. In contrast to clinical expectations, the prognostic value of ADL-dependency and impaired cognition remains unclear, and factors in the domains of emotional and communicative functioning rarely feature. Studies using a selected group of stroke patients tended to identify different predictors., Conclusions: The current evidence is insufficient for the development of a clinical prediction tool that is better than physicians' informal predictions. Future research should focus on the selection of optimal screening instruments in multiple domains of functioning, including the timing of assessment. We suggest developing prediction tools stratified by more homogeneous, clinically distinguished stroke subtypes., Implications for Rehabilitation: A reliable prognosis soon after a stroke is highly relevant to patients who ultimately have a poor outcome, because it enables early planning of care tailored to their needs. In view of the development of a clinical prediction tool that is better than physicians' informal predictions, future research should focus on optimal screening instruments in multiple domains of functioning, including emotional and communicative functioning. Clinical prediction tools stratified by more homogeneous, clinically distinguished stroke subtypes, could enable more accurate prognosis in individual stroke patients.

Objectives: In view of the development of an integrated care and treatment program for institutionalized stroke patients tailored to their needs, we aimed to explore their status of functioning in the physical, cognitive, emotional, communicative and social domains. In addition, we explored the relation between status of functioning and stroke characteristics., Design: A cross-sectional, observational study., Setting: Dutch nursing homes (NHs)., Participants: Residents with stroke as main diagnosis for NH-admission, who experienced a stroke ≥3 months ago and stayed ≥1 month in a long term care ward., Measurements: Attending physicians provided information about stroke subtype, stroke location and time post-stroke. Status of functioning was measured through an observation list comprising the Barthel Index, the Neuropsychiatric Inventory Questionnaire, and sections of the Resident Assessment Instrument for Long-Term Care Facilities. The list was filled out in a structured interview with a qualified nurse assistant who knew the resident well., Results: We included 274 residents (mean age 76.6, 58.4% female). The stroke that caused NH-dependency was in 81.3% ischemic, and in 49.8% right-sided. Median time post-stroke was 47 months; 90.9% of the residents were severely dependent in basic activities of daily living and 58% were in pain. Nearly half of the residents showed moderate (24.4%) or severe (23%) cognitive impairment. Irritability (52.9%), depressive symptoms (52.6%) and apathy (34.3%) occurred as the most frequent neuropsychiatric symptoms; 27.7% had a poor ability to express themselves and 30.3% had a low social engagement. We found more severe cognitive impairment, agitation/aggression and poor expression in left-sided strokes, more nighttime behavioral disturbances and delusions in right-sided strokes, and lower social engagement in residents with the largest time-interval post-stroke., Conclusion: This study among institutionalized stroke patients in Dutch NHs revealed very high prevalence of impairments on all domains of functioning, above the well-known severe disabilities in basic activities of daily living. The monitoring and management of both pain and neuropsychiatric symptoms should be key elements in an integrated care and treatment program., (Copyright © 2012 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.)

Objective: In this follow-up study, the long-term influence of group living homes (GLHs) on informal caregiver distress was compared with modern yet regular nursing homes (NHs)., Method: Informal caregivers of GLH (N = 37) and NH residents (N = 49) were studied at the time of admission, 6 months thereafter, and approximately 24 months after admission. Repeated measures of ANOVA were performed to study group-by-time effects on psychopathology, role overload, and feelings of competence., Result: All outcomes of psychological distress in GLH caregivers showed significantly greater decline compared with NH caregivers during the first six months after admission. The course of psychological distress stabilized in both caregiver groups after six months., Conclusion: GLHs may have played a role in reducing caregiver burden during the first six months after the nursing home admission of the care recipient. The stabilization of caregivers' psychological distress between T1 and T2 may indicate that there is no further room for improvement in the GLH and NH groups after six months. The implication would be that both GLHs and NHs succeeded in keeping caregivers' distress relatively low over the long term. More knowledge is needed on whether and how caregivers' psychological distress after institutionalization of the care recipient can be reduced to a greater extent.

Objectives: To gain insight into how advance directives for euthanasia affect resident care in Dutch nursing homes., Design: Survey of elderly care physicians and additional qualitative interviews with a selection of elderly care physicians and relatives of people with dementia who had an advance directive for euthanasia., Setting: Dutch nursing home practice., Participants: Four hundred thirty-four elderly care physicians completed the general part of the questionnaire; 110 physicians provided case histories. Interviews were conducted with 11 physicians and eight relatives., Measurements: The questionnaire contained general questions about the incidence of advance directives for euthanasia in people with dementia. A second part involved questions about the most recent case of a person with dementia and an advance directive for euthanasia who had died. The interviews with elderly care physicians and relatives focused on further exploration of the decision-making process regarding adherence to the advance directive for euthanasia., Results: Despite law-based possibilities, advance directives for euthanasia of people with dementia were rarely adhered to, although they seem to have a supportive role in setting limitations on life-sustaining treatments. Elderly care physicians and relatives were found to be reluctant to adhere to advance directives for euthanasia. Not being able to engage in meaningful communication played a crucial role in this reluctance., Conclusion: Advance directives for euthanasia are never adhered to in the Netherlands in the case of people with advanced dementia, and their role in advance care planning and end-of-life care of people with advanced dementia is limited. Communication with the patient is essential for elderly care physicians to consider adherence to an advance directive for euthanasia of a person with dementia., (© 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.)

Background: As our society is ageing, nursing homes are finding it increasingly difficult to deal with an expanding population of patients with dementia and a decreasing workforce. A potential answer to this problem might lie in the use of technology. However, the use and application of surveillance technology in dementia care has led to considerable ethical debate among healthcare professionals and ethicists, with no clear consensus to date., Aim: To explore how surveillance technology is viewed by care professionals and ethicists working in the field, by investigating the ideal application of surveillance technology in the residential care of people with dementia., Methods: Use was made of the concept mapping method, a computer-assisted procedure consisting of five steps: brainstorming, prioritizing, clustering, processing by the computer and analysis. Various participants (ranging from ethicists to physicians and nurses) were invited on the basis of their professional background., Results: The views generated are grouped into six categories ranging from the need for a right balance between freedom and security, to be beneficial and tailored to the resident, and clearly defined procedures to competent and caring personnel, active monitoring and clear normative guidance. The results are presented in the form of a graphic chart., Conclusions: There appears to be an inherent duality in the views on using surveillance technology which is rooted in the moral conflict between safety and freedom. Elaboration of this ethical issue has proved to be very difficult.

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

Objective: To obtain insight into current practices regarding compliance with advance directives for euthanasia (ADEs) in cases of incompetent patients with dementia in Dutch nursing homes, in light of the legal possibility offered by the new euthanasia law to perform euthanasia in these cases., Methods: A written questionnaire was completed by 434 elderly care physicians (ECPs)., Findings: Over the years 2005-2006, many ECPs took care of patients with dementia and an ADE, actual life termination of these patients took place very rarely and never in incompetent patients. ECPs reported practical difficulties in determining the 'unbearableness' of the suffering and choosing the right moment of carrying out the ADE., Conclusions: Although the enactment of the Dutch euthanasia law in theory provided a window of opportunity for euthanasia in incompetent patients with dementia and an ADE, it has not led to obvious changes in compliance with ADEs of this patient group in practice. Crucial in the reticent attitudes of ECPs appears to be the impossibility of patient-physician communication. This raises questions on the feasibility of the law on this point. In our opinion, the role of ADEs in end-of-life care of patients with advanced dementia in the Netherlands deserves serious reconsideration., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: Technology has emerged as a potential solution to alleviate some of the pressures on an already overburdened care system, thereby meeting the growing needs of an expanding population of seriously cognitively impaired people. However, questions arise as to what extent technologies are already being used in residential care and how ethically and practically acceptable this use would be., Methods: A systematic literature review was conducted to explore what is known on the moral and practical acceptability of surveillance technologies in residential care for people with dementia or intellectual disabilities, and to set forth the state of the debate., Results: A total of 79 papers met the inclusion criteria. The findings show that application and use of surveillance technologies in residential care for vulnerable people generates considerable ethical debate. This ethical debate centers not so much around the effects of technology, but rather around the moral acceptability of those effects, especially when a conflict arises between the interests of the institution and the interests of the resident. However, the majority of articles lack in depth analysis. Furthermore, there are notable cultural differences between the European literature and American literature whereby in Britain there seems to be more ethical debate than in America. Overall however, there is little attention for the resident perspective., Conclusion: No ethical consensus has yet been reached, underlining the need for clear(er) policies. More research is thus recommended to determine ethical and practical viability of surveillance technologies whereby research should be specifically focused on the resident perspective.

This qualitative explorative survey aimed at investigating the personal experiences of elderly people with early-stage dementia with regard to their illness and the extent to which they experience their situation as 'suffering'. In the Netherlands insight in this suffering is relevant with regard to ongoing debate on euthanasia and physician assisted death in early dementia. Participants in the study were 24 elderly (mean age 76.3 years) diagnosed with early-stage Alzheimer's disease. The semi-structured interviews were transcribed verbatim, and qualitatively analyzed. The elderly were found to be very capable of sharing experiences about their disease. They indicated not to experience their situation 'as a whole' as one of dreadful suffering. The gradual progression, which is distinctive of Alzheimer's disease, also allows people to adapt and adjust to their changing situation. As a result, the actual experiences of the disease can, in a positive manner, deviate from their anticipatory beliefs. The experiences of the participants appeared less negative than the ideas 'healthy' elderly often have about a life with dementia. The results from this study emphasize the importance of listening to the voices of people with dementia. Communication with elderly with Alzheimer's disease, is in the early stages quite possible and essential for advance care planning to be adjusted to their actual wishes and needs.

Background: Although advance directives may seem useful instruments in decision-making regarding incompetent patients, their validity in cases of dementia has been a much debated subject and little is known about their effectiveness in practice. This paper assesses the contribution of advance directives to decision-making in the care of people with dementia, with a special focus on non-treatment directives and directives for euthanasia., Methods: The relevant problems from the ethical debate on advance directives in cases of dementia are summarized and we discuss how these relate to what is known from empirical research on the validity and effectiveness of advance directives in the clinical practice of dementia care., Results: The ethical debate focuses essentially on how to respond to the current wishes of a patient with dementia if these contradict the patient's wishes contained in an advance directive. The (very limited) empirical data show that the main factors in medical decision-making in such cases is not the patient's perspective but the medical judgment of the physician and the influence of relatives. Insight into the experiences and wishes of people with dementia regarding advance directives is totally lacking in empirical research., Conclusions: Ethics and actual practice are two "different worlds" when it comes to approaching advance directives in cases of dementia. It is clear, however, that the use of advance directives in practice remains problematic, above all in cases of advance euthanasia directives, but to a lesser extent also when non-treatment directives are involved. Although generally considered valid, their effectiveness seems marginal. Further empirical research into the (potential) value of advance directives in dementia care is recommended.

Objectives: The aim of this study was to investigate the effects of group living homes on quality of life and functioning of people with dementia., Methods: The study had a quasi-experimental design with a baseline measurement on admission and an effect measurement six months later. Participants were 67 residents in 19 group living homes and 97 residents in seven traditional nursing homes. DQOL and QUALIDEM measured quality of life, functional status was examined with MMSE, IDDD, RMBPC, NPI-Q and RISE from RAI. Use of psychotropic drugs and physical restraints was also assessed. Linear and logistic regression analyses analyzed the data., Results: After adjustment for differences in baseline characteristics, residents of group living homes needed less help with ADL and were more socially engaged. There were no differences in behavioral problems or cognitive status. Also after adjusting, two of the 12 quality of life subscales differed between the groups. Residents of group living homes had more sense of aesthetics and had more to do. While there were no differences in prescription of psychotropic drugs, residents of group living homes had less physical restraints., Conclusions: Group living homes had some beneficial effects on its residents, but traditional nursing homes performed well as well. Possible study limitations included the baseline differences between the study groups and the use of different informants on T0 and T1. Future nursing home care may very well be a combination of the best group living care and traditional nursing home care have to offer.

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

The objectives of this study were to determine the ability of the 30-, 15- and 8-item versions of the GDS for screening and assessing change in severity of depression in nursing home patients. The GDS and the MADRS were administered to 350 elderly NH-patients by trained interviewers. The presence of major (MaD) or minor depression (MinD) was evaluated with the Schedules for Clinical Assessment in Neuropsychiatry. Receiver Operator Characteristic (ROC) curves of the GDS-versions were performed to measure the ability to screen on depression. The ability to measure change in severity of depression was measured by differences in mean GDS-scores and mean MADRS-scores between patients with MaD, MinD and no depression, and expressed in terms of effect sizes. It was found that in ROC-curves all three GDS-versions performed well. The MADRS showed larger effect sizes for the differences between MaD, MinD and no depression than the GDS-versions. The effect sizes of the three GDS versions were comparable. We conclude that all three versions of the GDS can be used for screening on depression among NH-patients. The MADRS is superior to the GDS for assessment of (changes in) severity of depression, but the GDS also appears to be an acceptable instrument for this purpose and is less time-consuming.

Background: Among the general public there is a deep fear of developing dementia, which has led to an increasing number of people "at risk" seeking ways (such as advance directives) to avoid undergoing progressive mental decline. The views of people with dementia are vital in obtaining a real answer to the question of how the disease affects people's lives and whether it actually involves the suffering that so many fear., Method: A review of the international literature is provided on what is known about living through dementia from the patient's perspective., Results: A total of 50 papers met the inclusion criteria. The findings of these reviewed papers give insight into the impact of dementia and the ways that those who have it deal with its effects by using different coping strategies. The literature on the perspective of the patient gives no solid support to the widespread assumption that dementia is necessarily a state of dreadful suffering. Although the impact of dementia and the experiences of loss resulting in multiple "negative" emotions cannot be denied, our findings also indicate that people do not undergo the disease passively and use both emotion-oriented and problem-oriented coping strategies to deal with its challenges. The experiences of living through dementia as told by the sufferers appear to yield a more subtle picture than the assumptions made by the general public., Conclusion: The overview provides a good starting point for improving the adjustment of care to the experience and wishes of people with dementia.

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

This article discusses the results of a Concept Mapping, held to clarify the concept of small-scale group living for elderly with dementia. Seventeen experts from different backgrounds formulated 91 statements about small-scale group living. These were subsequently depicted on a concept map with two dimensions: care versus living and individual versus context. The statements were then divided into six clusters by hierarchical cluster analysis. Five of these clusters centred around the arrangements of the individual lives of the residents and the collective lives of residents and staff, while only one held statements about the physical characteristics of small-scale group living. Therefore, it can be concluded from this Concept Map that small-scale group living is not so much determined by the physical characteristics but by the organisational features of the care context.

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

Objectives: To assess incidence and outcome of depressive symptoms among nursing home (NH) patients and to identify clinical characteristics predicting onset and persistence of depressive symptoms., Methods: Depressive symptoms (GDS>10) and relevant correlates were assessed at baseline and at follow-up (6 months) in 350 NH-patients of 14 Dutch NH's with the Geriatric Depression Scale (GDS). Predictors of onset and persistence were studied using chi-square statistics and multiple logistic regression analyses., Results: The prevalence of depressive symptoms decreased from 41.3% to 28.9% during six months follow-up. The onset of depressive symptoms in those without depressive symptoms at baseline was 4.7%, while the rate of persistence was 63.3%. Persistence of depressive symptoms was more frequent in patients with higher GDS-scores (18-30) at baseline. No baseline characteristics were associated with onset of depressive symptoms. Persistence of depressive symptoms was only associated with more years of education., Conclusions: Pre-admission factors and transition may largely be responsible for depressive symptoms among nursing home patients. The observed substantial decrease in prevalence of depressive symptoms over six months is largely due to remission of depressive symptoms present at baseline. Adaptation of nursing home patients to pre-admission factors, facilitated by the nursing home environment, may explain this observed decrease of depressive symptoms. Future studies should evaluate interventions targeted at patients with higher GDS-scores (18-30).

Objective: To determine the impact of depression and anxiety on well being, disability and use of health care services among nursing patients., Methods: The study-population consisted of 350 elderly nursing home patients from 14 nursing homes in the Netherlands. Well being, disability, use of health care services (i.e. assistance in ADL, paramedical care, number of medications) and depression and anxiety and other relevant characteristics (gender, age, education, marital status, urbanization, cognition, morbidity, social support) were measured cross-sectionally. Associations of well being, disability and use of health care services with independent baseline characteristics were assessed with bivariate and with multivariate analyses., Results: Presence of depression and/or anxiety was associated with significantly less well being, but not with more disability. Presence of depression and/or anxiety was also significantly associated with four of the seven indicators of health care service use measured in this study: less assistance in ADL, more consultation of medical specialists, a higher mean number of medications and more use of antidepressants., Conclusion: Presence of depression and/or anxiety has a statistically and clinically significant negative impact on well being, but not on disability. Future studies should focus on interventions for improving the detection, diagnosis and treatment of depression and/or anxiety in the nursing home., (Copyright (c) 2006 John Wiley & Sons, Ltd.)

Background: Very little is known about the prevalence and correlates of anxiety among nursing home patients. The current knowledge is predominantly based on information from population-based studies among elderly., Methods: Prevalence of anxiety was measured with the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) in a sample of 333 nursing home patients of somatic wards of 14 nursing homes in the Netherlands. Participants were over 55 years, had a MMSE-score >14 and were able to communicate sufficiently. Information about demographic, health-related, psychosocial and care-related characteristics was collected in interviews with participants and from attending physicians and nursing home staff., Results: The prevalence of anxiety disorders was 5.7%, of subthreshold anxiety disorders 4.2% and of anxiety symptoms 29.7%. Only health-related characteristics (MMSE-score >23, depression, stroke) were significantly associated with anxiety disorders and subthreshold anxiety disorders. Demographic (>6 years education), health-related (depression, impaired vision, pain) and psychosocial characteristics (a recent negative life event) were significantly associated with anxiety symptoms. No care-related characteristics were associated with anxiety., Limitations: The study population is a selective one (>55 years, MMSE >15, able to communicate sufficiently). The data were collected cross-sectionally., Conclusions: Anxiety disorders and anxiety symptoms occur frequently among nursing home patients and are mainly associated with health-related characteristics. Physicians should focus special attention on patients with depression or stroke.

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

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

The purpose of this study was to investigate and analyze the moral tension that exists in the care for demented nursing home patients, between the principle of respect for autonomy and the value that is attached to respect for the subjective world of the patient. To this end an ethnographical field study was carried out by two researchers in two Dutch nursing homes. Among the central topics that evolved were the different moral problems that nurses experience concerning truth telling and acting truthfully in relation to demented patients. In situations unrelated to the dementia and its diagnosis, the right to be informed is in principle respected, even if the information is sometimes painful. More specific questions of demented patients about their situation are a regular cause of embarrassment for their carers, who rely on various treatment strategies to deal with such questions. These strategies are often successful. However, when they fail, the nurses are faced with a problem they cannot solve, namely the loss of a common shared world and the resulting unmentionable truth about the diagnosis of dementia, as objective basis and legitimization for their approach to the demented patient. We conclude that in the training and professional support given to nurses, more attention should be paid to (awareness of) the moral problems that arise from this loss of a common shared world, so that they can react to the subjective world of demented patients without feeling that they are deceiving them.

Psychiatric disorders such as dementia and depression are highly prevalent in nursing homes. The prevalence of anxiety disorders is less clear. Prevalence, course and risk-indicators of anxiety disorders among nursing home residents were examined, based on a review of the literature. Medline and PsychINFO searches were conducted for 1966-2002. Twelve studies were considered relevant. These differed substantially with respect to study-population, diagnostic instruments and diagnostic criteria that were used and the specific anxiety disorders investigated. The prevalence of anxiety disorders ranged from 0-20%. Only in one study the course of anxiety disorders was investigated. About 60% of the nursing home residents recovered in one year. The most important risk-indicators for anxiety disorders identified were: female sex, depression, lack of social support, poor physical health and functional and cognitive impairments. Generalization of these results to the Dutch nursing home population is restricted by the substantial heterogeneity of the studies. Further studies are required to provide reliable estimates of prevalence, course and risk-indicators of anxiety disorders among nursing home residents using appropriate diagnostic instruments and adjusted diagnostic criteria. This will enhance detection and improve treatment of anxiety disorders among nursing home residents.

Objectives: To examine predictors of survival time and causes of mortality in a population-based cohort of demented subjects., Design: Longitudinal naturalistic follow-up study., Setting: A rural area in The Netherlands., Participants: The study population consisted of 102 demented subjects derived from a population-based, two-stage prevalence study of dementia among subjects aged 65 and over., Measurements and Analysis: Survival analysis was performed using the Realized Probability of Dying as a measure of survival time. Adjustment for duration and severity at study entry was employed in all analyses., Results: A substantial excess mortality was present among demented subjects as compared with their non-demented birth cohort. Disorders related to dementia, such as cachexia, dehydration and pneumonia, were major causes of death. Variables related to severity of functional impairment, aphasia and a shorter duration at study entry predicted a shorter survival in the study population., (Copyright 1999 John Wiley & Sons, Ltd.)

To obtain estimates of the prevalence of mild and moderate/severe dementia among people age 65 and over, applying criteria for severity of both DSM-III-R and CAMDEX, a two-stage community-based study was conducted in a rural area of the Netherlands. In the first stage, 2191 subjects (out of the target population of 2655) participated in an interview which included the Mini-Mental State Examination (MMSE). Based on MMSE score, a non-proportional random sample (n=496) was drawn for the second stage. A total of 421 subjects responded and were subsequently examined using the Cambridge Examination for Mental Disorders of the Elderly (CAMDEX). In determining the severity of dementia, criteria of both DSM-III-R and CAMDEX were applied. Overall prevalence for both classification systems was 6.5%. There was a large discrepancy between the two classification systems with regard to the criteria for rating severity. The prevalence of moderate/severe dementia using DSM-III-R criteria was twice as high as the prevalence using CAMDEX criteria. These findings reflect the differences between DSM-III-R and CAMDEX in descriptions of dementia severity. Rating according to CAMDEX predicts institutionalization in specialized nursing homes somewhat better than staging according to DSM-III-R. Both content analysis and institutionalization data suggest that the CAMDEX operationalization of rating severity seems preferable.

Aim: The objective of this study was to examine service utilization figures among a representative sample of demented patients and to determine whether sociodemographic and health-related variables are associated with care utilization., Method: The study population was derived from a population-based, two-stage cross-sectional study in The Netherlands and consisted of 102 demented subjects. Four levels of care intensity were used: level 1, no use of professional care; level 2, use of one or more types of professional care by community-dwelling subjects; level 3, residential living in homes for the aged; level 4, long-term care in specialized nursing homes. Sociodemographic variables and variables related to mental and physical health, functional dependency and severity of dementia were studied as determinants of levels of care., Results: Eighty-two per cent of the study subjects used one or more types of formal care and 55% were institutionalized. Multivariate analysis yielded age, severity of dementia, somatic disorders, dependency in terms of ADL and martial status as predictors of higher levels of care. Sets of predictors differed across different care levels., Conclusions: The findings point to the importance of the social network and the relevance of general medical treatment and an active approach towards decreasing the impact of ADL dependency in demented subjects.

Objective: To establish the criterion validity of the MMSE for dementia in a community-based population., Design: Descriptive., Setting: Eight rural general practices and eight adherent institutions for long-term care near Zwolle, the Netherlands., Methods: In the first (screening) stage, the MMSE was applied, in the second (diagnostic) stage the 'Cambridge examination for mental disorders of the elderly' (CAMDEX) was used. After exclusion of subjects with clinically relevant impairment of hearing and (or) vision, analyses were based on 2151 screened subjects. Based on a non-proportional, stratified randomized sampling procedure using the MMSE score as the stratification variable, 390 of the screened subjects were examined with the CAMDEX. Seventy-seven cases of DSM-III-R dementia were identified. Based on 390 paired observations the relationship between MMSE score and DSM-III-R dementia was modelled by logistic regression. After extrapolation of this relationship to the total screened population, sensitivity and specificity figures were calculated at several cut-offs of the MMSE, and Receiver Operating Characteristic (ROC) curves were constructed for the total population as well as for four subpopulations. (men, women, < 80, > or = 80 years)., Results: At the cut-off of 23/24, sensitivity was 0.76 and specificity 0.91 in the total population. However, the criterion validity of the MMSE varied substantially between the four sex-age combinations. Criterion validity was especially poor for women in the younger age range., Conclusion: The MMSE has only limited value in clinical practice. Use of uniform cut-offs has to be rejected.

A study was conducted, which simultaneously used GPs and epidemiological assessment procedures (MMSE, CAMDEX), to identify individuals with DSM-III-R dementia in the same population. In addition, a 1-year follow-up assessment was conducted in patients with a CAMDEX-diagnosis of dementia. In the non-institutionalized group, which was assessed both by the GP and with the epidemiological test battery, the prevalence of dementia according to the GP was 2.2%, whereas the prevalence based on the epidemiological approach amounted to 5.2%. In general CAMDEX-diagnoses of dementia were confirmed at 1-year follow-up, and thus the discrepancy between the two prevalence estimates must be attributed to the low sensitivity of the GPs. Sensitivity of the GP was related to help-seeking behaviour, with low sensitivity in patients with a low contact rate. It was also related to the use of less specific diagnostic labels by the GP (cognitive impairment), and to poor recognition of cognitive impairment in patients who visited their GP.

In the Netherlands both nursing homes and homes for the aged serve as a residence for demented elderly. Although these institutions differ considerably regarding financing and care facilities, specific functions of each institute concerning demented elderly have not been clearly defined. In order to know to what extent residential facilities serve demented elderly, the prevalence and severity of dementia among residents aged 65 and over was studied as part of a prevalence study among elderly people in a rural area of the Netherlands. The target population existed of all persons aged 65 and over who were registered in eight general practices. Patients who had to leave the practice on account of ill-health and were admitted to nursing homes were included in the study. In a two stage study the MMSE was applied as a screening instrument. Based on MMSE-score a non-proportional stratified random sample was drawn for the second, diagnostic stage, which existed of the CAMDEX. Prevalence estimates for DSM-III-R-dementia were 21% among residents of homes for the aged, 48% among residents of somatic wards of nursing homes and 100% among those admitted to psychogeriatric wards of nursing homes. Severity of dementia was highest among residents of psychogeriatric wards of nursing homes and lowest among those living in homes for the aged. Prevalence of dementia among residents of homes for the aged can be fully attributed to the age-distribution. The high frequency of dementia among residents of somatic nursing home wards can be explained in several ways: First, admission can be necessary due to a combination of dementia and somatic illness.(ABSTRACT TRUNCATED AT 250 WORDS)

A pilot investigation among 15 general practitioners in the region of Zwolle has been carried out in order to obtain an indication as to the prevalence of the dementia syndrome among noninstitutionalized elderly people. According to the general practitioner--on the basis of the Clinical Dementia Rating--4.4% of the population of people of 65 years and older display the symptoms of dementia, a percentage that is low compared with foreign studies. There is a striking difference in the prevalence rate between urban (2.8%) and rural (5.7%) populations. The most obvious explanation for this difference is that in rural areas there is more informal care and a larger degree of tolerance of demented elderly people, which helps prevent institutionalization. This assumption is supported by an identical difference in the admission rate to nursing homes. As a person becomes older, the chance that he/she will suffer from the dementia syndrome increases, although the increase is not a steady one. Despite the well-recognized necessity for thorough medical examination of demented elderly people, it is only carried out to a small degree. The authors argue in favour of more extensive research into the prevalence rate of the dementia syndrome, which will promote policy making with regard to medical practice and the planning of care facilities.