In this thesis, the effectiveness and feasibility of two proactive care programs, implemented in the emergency department (ED) of Haaglanden Medical Center in The Hague are evaluated. The first... Show moreIn this thesis, the effectiveness and feasibility of two proactive care programs, implemented in the emergency department (ED) of Haaglanden Medical Center in The Hague are evaluated. The first part of the thesis focuses on a screening and intervention program for hazardous alcohol use in adult ED patients. Although in the subset of patients reached for follow-up, receiving an intervention was associated with reduced alcohol consumption after three months, many patients were not screened and less than half of eligible patients received an intervention. Moreover, risk factors for hazardous alcohol use were more common in unscreened than in screened patients. In the second part of the thesis, the effect of telephone follow-up after ED discharge for community-dwelling older patients on health-related outcomes, including unplanned hospital admissions and ED return visits within 30 days, is examined. As the intervention turned out not to be effective, we investigated reasons for unplanned ED return visits in older adults to assess whether post-ED discharge interventions are sufficiently attuned to the reasons for unplanned ED return.In conclusion, none of the interventions were effective. Moreover, feasibility of the programs was limited, as many eligible patients were not reached, due to both staff-related and patient-related reasons. Show less
Background: Gene expression signatures have emerged to predict prognosis and guide the use of adjuvant therapy in patients with hormone receptor-positive breast cancer. The objective of this... Show moreBackground: Gene expression signatures have emerged to predict prognosis and guide the use of adjuvant therapy in patients with hormone receptor-positive breast cancer. The objective of this systematic review was to evaluate the prognostic and predictive value of commercially available gene expression signatures as a tool in adjuvant treatment decision-making in older patients with breast cancer.Methods: PubMed, MEDLINE, Embase, Web of Science, Cochrane Library, and Emcare were reviewed for relevant articles published before December 2021. Eligible studies were randomised trials and cohort studies that externally validated commercially available gene expression signatures in patients aged 65 years and older, including studies that presented subanalyses of this age group. Data extraction and risk of bias assessment was performed independently by two investigators.Results: Fifteen studies were included. Most studies investigated Oncotype DX, while results from other gene expression signatures were limited. Several studies underlined the prognostic performance of Oncotype DX and Prosigna Risk of Recurrence in older patients. Moreover, Oncotype DX was predictive for older patients with an intermediate-risk recurrence score; chemotherapy could be spared in both lymph node-positive and lymph node -negative disease.Conclusions: Prognostic performance has been demonstrated in older patients for several gene expression sig-natures. However, additional validation in patients with high-risk tumours is needed before gene expression signatures can be implemented in clinical practice as a prediction tool for adjuvant chemotherapy decision -making in the older age group. Show less
Coronavirus disease 2019 (COVID-19) poses a threat to the health and independence of older people in particular. In this article we elaborate on the content and importance of post-acute COVID-19... Show moreCoronavirus disease 2019 (COVID-19) poses a threat to the health and independence of older people in particular. In this article we elaborate on the content and importance of post-acute COVID-19 geriatric rehabilitation from a European perspective. We explain the geriatric rehabilitation paradox and how this can and should be solved. We also present what post-acute COVID-19 geriatric rehabilitation should entail. This might not only help us to develop better geriatric rehabilitation services, but it should also inform pandemic preparedness in the future. Show less
Due to a shorter remaining life expectancy, the risk of recurrence in older patients with low risk breast cancer is often reduced and the benefit of treatments may be very limited, especially with... Show moreDue to a shorter remaining life expectancy, the risk of recurrence in older patients with low risk breast cancer is often reduced and the benefit of treatments may be very limited, especially with adjuvant treatments. In the first part of this thesis, we studied the interplay between breast cancer mortality and other-cause mortality. In the second part of this thesis, we investigated the effect of surgery and radiotherapy in subsets of the older population of patients with breast cancer in which the actual treatment effect is questionable. Show less
Verberne, W.R.; Stiggelbout, A.M.; Bos, W.J.W.; Delden, J.J.M. van 2022
An increasing number of older patients have to decide on a treatment plan for advanced chronic kidney disease (CKD), involving dialysis or conservative care. Shared decision-making (SDM) is... Show moreAn increasing number of older patients have to decide on a treatment plan for advanced chronic kidney disease (CKD), involving dialysis or conservative care. Shared decision-making (SDM) is recommended as the model for decision-making in such preference-sensitive decisions. The aim of SDM is to come to decisions that are consistent with the patient's values and preferences and made by the patient and healthcare professional working together. In clinical practice, however, SDM appears to be not yet routine and needs further implementation. A shift from a biomedical to a person-centered conception might help to make the process more shared. Shared should, therefore, be interpreted as two persons bringing two perspectives to the table, that both need to be explored during the decision-making process. Starting from the patient's perspective will enable to determine the mutual goals of care first and, subsequently, determine the best way for achieving those goals. To perform such SDM, the healthcare professional needs to become a skilled companion, being part of the patient's relational context, and start asking the right questions about what matters to the patient as person. In this article, we describe the need for a person-centered conception of SDM for the setting of older patients with advanced CKD. Show less
Purpose Older people often present to the Emergency Department with nonspecific complaints. We aimed (1) to examine characteristics of older patients presenting to the ED triaged with the... Show morePurpose Older people often present to the Emergency Department with nonspecific complaints. We aimed (1) to examine characteristics of older patients presenting to the ED triaged with the presentational flowchart 'unwell adult' of the Manchester triage system (MTS) and (2) to assess the different mortality and admission rates among triage categories. Methods Retrospective cohort study including all consecutive patients aged 70 years and older who visited the ED of a tertiary care hospital in the Netherlands during a 1-year period. The primary outcome was 30-day mortality. Secondary outcomes were 7-day mortality, hospital admission and ED length of stay. Results 4255 patients were included in this study. Mean age was 78 years (IQR 73.9-83.4) and 2098 were male (49.3%). The MTS presentational flowchart 'unwell adult' was the most commonly used flowchart (n = 815, 19.3%). After the infrequent flowchart 'major trauma' (n = 9, 13.8%), 'unwell adult' had the highest 30-day mortality (n = 88, 10.8%). When compared to all other flowcharts, patients assigned as 'unwell adult' have significantly higher 30-day mortality rates (OR 1.89 (95%CI 1.46-2.46), p = < 0.001), also when adjusted for age, gender and triage priority (OR 1.75 (95%CI 1.32-2.31), p = < 0.001). Patients from the 'unwell adult' flowchart had the highest hospital admission rate (n = 540, 66.3%), and had among the longest ED length of stay. Conclusions Older ED patients are most commonly assigned the presentational flowchart 'unwell adult' when using the MTS. Patients in this category have the highest non-trauma mortality and highest hospital admission rates when compared to other presenting complaints.Key summary pointsAim Examine characteristics of older patients presenting to the ED triaged with the presentational flowchart 'unwell adult' of the Manchester triage system (MTS) and to assess the different mortality and admission rates among triage categories. Findings Older patients assigned to the 'unwell' flowchart have the highest non-trauma mortality rate, independent of urgency category, and highest admission rates of all presenting complaints. Surprisingly, mortality was also observed in the lowest triage categories. Message Patients in the category 'unwell' have the highest non-trauma 30-day mortality and highest hospital admission rates when compared to other presenting complaints, indicating that the nonspecific disease presentation "unwell" is a serious medical condition. Show less
As the population is aging worldwide, and in spite of all preventive efforts, age-related diseases are increasingly prevalent, such as cardiovascular diseases and cognitive impairment. Different... Show moreAs the population is aging worldwide, and in spite of all preventive efforts, age-related diseases are increasingly prevalent, such as cardiovascular diseases and cognitive impairment. Different vascular risk factors, both the ‘traditional’ modifiable factors, such as hypertension or diabetes, and non-modifiable factors, such as age or gender, can lead to different kind of intertwined micro- and macrovascular diseases in various or multiple simultaneous organs. There is a growing need for knowledge regarding the interplay between different (co)morbidities, the relation of (co)morbidities with the various underlying pathophysiological mechanisms and treatment options of these (co)morbidities. Therefore, the aims of this thesis were to identify patients at high cardiovascular risk and to optimize treatment for these patients. We further unravelled the complexity of various interacting (poly) vascular diseases, ultimately leading to an increased risk of not only cognitive impairment, but also MACE including death. Identification of these patients and better understanding of the interplay and underlying mechanisms of these diseases is the first step towards preventive strategies. Treating these high risk patients can be a therapeutic challenge, but there is growing knowledge regarding both established and evolving therapies to optimize efficacy and efficiency. Show less
Older emergency department (ED) patients are at high risk of adverse health outcomes, such as mortality or functional decline. Early identification of those patients who are at highest risk gives... Show moreOlder emergency department (ED) patients are at high risk of adverse health outcomes, such as mortality or functional decline. Early identification of those patients who are at highest risk gives an opportunity to target interventions and guide treatment decisions for those who need it most.This thesis describes the clinical value of using geriatric screening in the ED. Geriatric screening identifies older patients at high risk of both short- and long-term poor outcomes and provides valuable information for care providers treating acutely hospitalized older patients. The results from screening could aid in individualized treatment decisions to acquire more personalized care, and therefore gives an opportunity to optimize outcomes for older patients.Implementation of screening programs in the fast-paced environment of everyday ED practice remains scarce. The results of this thesis show that the implementation of a geriatric screening program in routine ED practice is feasible and the use of screening is accepted by both the users (triage nurses) and the older patients.Using geriatric screening in routine care is therefore useful and feasible. More research will be needed to investigate implementation in different hospitals to generate guidance on how geriatric screening tools can be successfully implemented on a wide scale. Show less
Loon-van Gaalen, M. van; Winsen, B. van; Linden, M.C. van der; Gussekloo, J.; Mast, R.C. van der 2021
Background Older patients discharged from the emergency department (ED) are at increased risk for adverse outcomes. Transitional care programs offer close surveillance after discharge, but are... Show moreBackground Older patients discharged from the emergency department (ED) are at increased risk for adverse outcomes. Transitional care programs offer close surveillance after discharge, but are costly. Telephone follow-up (TFU) may be a low-cost and feasible alternative for transitional care programs, but its effects on health-related outcomes are not clear. Aim We systematically reviewed the literature to evaluate the effects of TFU by health care professionals after ED discharge to an unassisted living environment on health-related outcomes in older patients compared to controls. Methods We conducted a multiple electronic database search up until December 2019 for controlled studies examining the effects of TFU by health care professionals for patients aged >= 65 years, discharged to an unassisted living environment from a hospital ED. Two reviewers independently assessed eligibility and risk of bias. Results Of the 748 citations, two randomized controlled trials (including a total of 2120 patients) met review selection criteria. In both studies, intervention group patients received a scripted telephone intervention from a trained nurse and control patients received a patient satisfaction survey telephone call or usual care. No demonstrable benefits of TFU were found on ED return visits, hospitalization, acquisition of prescribed medication, and compliance with follow-up appointments. However, many eligible patients were not included, because they were not reached or refused to participate. Conclusions No benefits of a scripted TFU call from a nurse were found on health services utilization and discharge plan adherence by older patients after ED discharge. As the number of high-quality studies was limited, more research is needed to determine the effect and feasibility of TFU in different older populations. PROSPERO registration number CRD42019141403. Show less
Background: Treatment decisions concerning older patients can be very challenging and individualised treatment plans are often required in this very heterogeneous group. In 2015 we have implemented... Show moreBackground: Treatment decisions concerning older patients can be very challenging and individualised treatment plans are often required in this very heterogeneous group. In 2015 we have implemented a routine clinical care pathway for older patients in need of intensive treatment, including a comprehensive geriatric assessment (CGA) that was used to support clinical decision making. An ongoing prospective cohort study, the Triaging Elderly Needing Treatment (TENT) study, has also been initiated in 2016 for participants in this clinical care pathway, to study associations between geriatric characteristics and outcomes of treatment that are relevant to older patients. The aim of this paper is to describe the implementation and rationale of the routine clinical care pathway and design of the TENT study.Methods: A routine clinical care pathway has been designed and implemented in multiple hospitals in the Netherlands. Patients aged >= 70 years who are candidates for intensive treatments, such as chemotherapy, (chemo-)radiation therapy or major surgery, undergo frailty screening based on the Geriatric 8 (G-8) questionnaire and the Six-Item Cognitive Impairment Test (6CIT). If screening reveals potential frailty, a CGA is performed. All patients are invited to participate in the TENT study. Clinical data and blood samples for biomarker studies are collected at baseline. During follow-up, information about treatment complications, hospitalisations, functional decline, quality of life and mortality is collected. The primary outcome is the composite endpoint of functional decline or mortality at 1 year.Discussion: Implementation of a routine clinical care pathway for older patients in need of intensive treatment provides the opportunity to study associations between determinants of frailty and outcomes of treatment. Results of the TENT study will support individualised treatment for future patients.Trial registration: The study is retrospectively registered at the Netherlands Trial Register (NTR), trial number NL81 07. Date of registration: 22-10-2019. Show less
Background The prevalence of impaired cognitive functioning in older patients with end stage kidney disease (ESKD) is high. We aim to describe patterns of memory, executive function or psychomotor... Show moreBackground The prevalence of impaired cognitive functioning in older patients with end stage kidney disease (ESKD) is high. We aim to describe patterns of memory, executive function or psychomotor speed and to identify nephrologic, geriatric and neuroradiologic characteristics associated with cognitive impairment in older patients approaching ESKD who have not yet started with renal replacement therapy (RRT). Methods The COPE-study (Cognitive Decline in Older Patients with ESRD) is a prospective cohort study including 157 participants aged 65 years and older approaching ESKD (eGFR <= 20 ml/min/1.73 m(2)) prior to starting with RRT. In addition to routinely collected clinical parameters related to ESKD, such as vascular disease burden and parameters of metabolic disturbance, patients received a full geriatric assessment, including extensive neuropsychological testing. In a subgroup of patients (n = 93) a brain MRI was performed. Results The median age was 75.3 years. Compared to the normative data of neuropsychological testing participants memory performance was in the 24th percentile, executive function in the 18th percentile and psychomotor speed in the 20th percentile. Independent associated characteristics of impairment in memory, executive and psychomotor speed were high age, low educational level and low functional status (all p-values < 0.003). A history of vascular disease (p = 0.007) and more white matter hyperintensities on brain MRI (p = 0.013) were associated with a lower psychomotor speed. Conclusion Older patients approaching ESKD have a high prevalence of impaired memory, executive function and psychomotor speed. The patterns of cognitive impairment and brain changes on MRI are suggestive of vascular cognitive impairment. These findings could be of potentially added value in the decision-making process concerning patients with ESKD. Show less
The number of older people in the population is rising and so is the number of older patients in the Emergency Department (ED). Older patients often have complex problems which leads to an... Show moreThe number of older people in the population is rising and so is the number of older patients in the Emergency Department (ED). Older patients often have complex problems which leads to an increased change of repeat ED visits, longer length of stay, higher chance of hospital admission and higher chance of negative health outcomes. Cognitive impairment is a frequent problem in older ED patients but often remains unrecognized and little is known about the association between cognitive impairment and adverse outcomes in older ED patients. In this thesis we show that cognitive impairment is associated with adverse outcomes in acutely presenting older patients. Secondly, we show that routinely collected parameters in addition to cognitive impairment can be used to screen for high risk of adverse outcomes in older ED patients. We investigated two delirium screeners and showed the CAM-ICU might not be suitable for early detection of delirium in the ED. Finally, vital signs that associate with decreased brain perfusion and oxygenation, such as low systolic blood pressure, were associated with cognitive impairment in older ED patients. Next steps would be to investigate if optimal resuscitation might improve cognition and decrease risk of subsequent delirium and adverse outcomes. Show less
The rate of adverse health outcomes 90 days after an emergency department (ED) visit is high for older patients.A comprehensive geriatric assessment (CGA) can effectively identify patients at... Show moreThe rate of adverse health outcomes 90 days after an emergency department (ED) visit is high for older patients.A comprehensive geriatric assessment (CGA) can effectively identify patients at highest risk and improve outcomes. Unfortunately, the fast-paced environment and the medical condition of the acutely ill older patient make it virtually impossible to perform a CGA in all patients in the ED. Therefore, it was the aim of the present thesis to develop a screening instrument for the ED setting to identify older patients at high risk for adverse health outcomes, in order to target them for future interventions to preserve their independency and quality of life. In a multicenter prospective cohort study a total of 2629 older ED patients were included with a mean age of 79 years old. After 90 days 805 patients (30.6%) experienced functional decline or mortality. A new screeninginstrument to identify older ED patients at risk for adverse health outcomes was developed and validated: the APOP screener. The APOP screener adequately identifies older ED patients at highest risk for functional decline or mortality and is promising for clinical use. Show less
Sijp, M.P.L. van der; Eijk, M. van; Krijnen, P.; Schipper, I.B.; Achterberg, W.P.; Niggebrugge, A.H.P. 2018
