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Background: Concern has been raised that the COVID-19 pandemic and consequent social distancing measures may increase neuropsychiatric symptoms in people with dementia. Thus, we developed and delivered an e-learning training course to professional caregivers on using a web-based tool for psychosocial interventions for people with dementia. Objective: The aim of our study was to evaluate the feasibility and efficacy of an e-learning course in combination with a web-based tool in addressing neuropsychiatric symptoms of dementia. Methods: A quasi-experimental design was used in Tokyo, Japan. The e-learning course was delivered three times to professional caregivers between July and December 2020. Caregivers who completed the course assessed the level of neuropsychiatric symptoms in people with dementia using the total score from the Neuropsychiatric Inventory (NPI) via a web-based tool. The primary outcome measures were the number of caregivers who implemented follow-up NPI evaluations by March 2021 and the change in NPI scores from baseline to their most recent follow-up evaluations. As a control group, information was also obtained from professional caregivers who completed a face-to-face training course using the same web-based tool between July 2019 and March 2020. Results: A total of 268 caregivers completed the e-learning course in 2020. Of the 268 caregivers, 56 (20.9%) underwent follow-up evaluations with 63 persons with dementia. The average NPI score was significantly reduced from baseline (mean 20.4, SD 16.2) to the most recent follow-up evaluations (mean 14.3, SD 13.4). The effect size was assumed to be medium (Cohen drm [repeated measures]=0.40). The control group consisted of 252 caregivers who completed a face-to-face training course. Of the 252 caregivers, 114 (45.2%) underwent follow-up evaluations. Compared to the control group, caregivers who completed the e-learning course were significantly less likely to implement follow-up evaluations (χ21=52.0, P<.001). The change in NPI scores did not differ according to the type of training course (baseline-adjusted difference=–0.61, P=.69). Conclusions: The replacement of face-to-face training with e-learning may have provided professionals with an opportunity to participate in the dementia behavior analysis and support enhancement (DEMBASE) program who may not have participated in the program otherwise. Although the program showed equal efficacy in terms of the two training courses, the feasibility was suboptimal with lower implementation levels for those receiving e-learning training. Thus, further strategies should be developed to improve feasibility by providing motivational triggers for implementation and technical support for care professionals. Using online communities in the program should also be investigated.

This article describes the coaching strategies of the NESTORE e-coach, a virtual coach for promoting healthier lifestyles in older age. The novelty of the NESTORE project is the definition of a multi-domain personalized pathway where the e-coach accompanies the user throughout different structured and non-structured coaching activities and recommendations. The article also presents the design process of the coaching strategies, carried out including older adults from four European countries and experts from the different health domains, and the results of the tests carried out with 60 older adults in Italy, Spain and The Netherlands.

Background: Neuropsychiatric symptoms occur frequently in many nursing home residents with dementia. Despite the availability of multidisciplinary guidelines, neuropsychiatric symptoms are often inadequately managed. Three proven effective methods for managing neuropsychiatric symptoms were integrated into a single intervention method: the STIP-Method, a personalized integrated stepped-care method to prevent and treat neuropsychiatric symptoms. The STIP-Method comprises 5 phases of clinical reasoning to neuropsychiatric symptoms and 4 stepped-care interventions and is supported with a web application. Objective: This study aims to identify the facilitators and barriers in the implementation of the STIP-Method in nursing homes. Methods: A mixed methods design within a participatory action research was used to implement the STIP-Method in 4 facilities of 2 Dutch nursing home organizations. In total, we aimed at participation of 160-200 persons with dementia and expected an intervention fidelity of 50% or more, based on earlier studies regarding implementation of effective psychosocial interventions to manage neuropsychiatric symptoms. All involved managers and professionals were trained in the principles of the STIP-Method and in using the web application. An advisory board of professionals, managers, and informal caregivers in each facility supported the implementation during 21 months, including an intermission of 6 months due to the COVID-19 pandemic. In these 6-weekly advisory board meetings, 2 researchers stimulated the members to reflect on progress of the implementation by making use of available data from patient records and the web application. Additionally, the 2 researchers invited the members to suggest how to improve the implementation. Data analysis will involve (1) analysis of facilitators and barriers to the implementation derived from verbatim text reports of advisory board meetings to better understand the implementation process; (2) analysis of patient records in accordance with multidisciplinary guidelines to neuropsychiatric symptoms: personalized, interdisciplinary, and proactive management of neuropsychiatric symptoms; (3) evaluation of the web application in terms of usability scores; (4) pre- and postimplementation analysis of patient records and the web application to evaluate the impact of the STIP-Method, such as changes in neuropsychiatric symptoms and informal caregiver burden. Results: We enrolled 328 persons with dementia. Data collection started in July 2019 and ended in December 2021. The first version of this manuscript was submitted in October 2021. The first results of data analysis are expected to be published in December 2022 and final results in June 2023. Conclusions: Our study may increase understanding of facilitators and barriers to the prevention and treatment of neuropsychiatric symptoms in nursing home residents with dementia by implementing the integrated STIP-Method. The need for well-designed implementation studies is of importance to provide nursing homes with optimal tools to prevent and treat neuropsychiatric symptoms. International Registered Report Identifier (IRRID): DERR1-10.2196/34550

Abstract Malnutrition in older adults occurs multifactorially and should be prevented interdisciplinary. This requires an improvement in the competencies regarding the integral prevention of malnutrition in students of different Bachelor’s programs, such as dietetics, social work and nursing, who are the future professionals. A precondition is that this education is taught by lecturers who have a positive attitude toward malnutrition education. However, it is unknown what this attitude is. We started our exploration within Bachelor of Nursing lecturers. Therefore, the aim of this study was to gain insight into the attitude of these lecturers regarding malnutrition education. A qualitative study, where semi-structured, in-depth interviews were held with nine Bachelor of Nursing lecturers from four different educational institutes. The interviews were transcribed and thematically analyzed. Two main themes emerged from the data: (1) ‘malnutrition is important’, subdivided in three sub-themes: ‘personal experiences’, ‘nursing experiences’ and ‘theoretical knowledge’, and (2) ‘not acting consequently’, subdivided in four sub-themes: ‘unclear responsibilities’, ‘insecurity regarding own abilities’, ‘depending on experts’ and ‘problems with prioritization’. The results showed that lecturers have a positive perception regarding malnutrition education, but that there is a discrepancy between their attitude and actual behavior. This means that this may lead to difficulties in embedding and providing qualitative malnutrition education in the curriculum. It is advised that lecturers follow train-the-trainer courses to develop and enhance their competencies in providing malnutrition education. Also, an efficient integration of and interdisciplinary approach regarding malnutrition education is advised.

Undernutrition is a major health problem in the growing elderly population. It is estimated that one in ten Dutch community-dwelling older adults is suffering from undernutrition, and one in three Dutch older adults who receive home care. Undernutrition may lead to many negative consequences, ranging from fatigue and falls to impaired immune function and death. This makes undernutrition an obvious target for preventive measures.Undernutrition can be defined as \"a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome\". In addition, it is often described as protein energy malnutrition. Adequate protein intake may to some extent prevent and reverse this process. However, throughout ageing, it becomes increasingly difficult to reach adequate protein intake due to higher protein needs and lower protein intakes. Finding solutions to assist older adults in reaching their optimal protein intake is necessary.In our overall research project, we considered 1.2g protein per kg weight per day (g/kg/d) as adequate protein intake. In Dutch community-dwelling older adults, protein intake is around 1.0 g/kg/d, implying room for improvement. However, it is possible that many of these older adults deal with physiological changes, medical conditions, and physical and mental limitations that impair their appetite and food provision. For these older adults with higher protein needs, merely recommending that they eat more would not be realistic. It would be more realistic to explore strategies that increase protein intake without having to increase food intake. This calls for the exploration of instruments that match the needs and preferences of older adults: protein-enriched regular products.One particular group that can be identified as a target group for such products, are older adults who receive home care. Undernutrition prevalence is high in this group, which may be explained by their health problems that led to this dependence on home care. Likewise, many of these older adults also depend on meals-on-wheels. These meals-on-wheels recipients, regardless of whether they receive home care or not, often risk undernutrition too. In both these (overlapping) care-dependent groups, difficulties in adhering to energy and protein recommendations can be discerned. For this reason, enriching the readymade meals that these older adults receive may contribute to the prevention of protein undernutrition by increasing protein intake while keeping food intake the same. Here, protein enrichment instruments can be used to prevent undernutrition, but only when implemented in a timely manner. Adequate undernutrition management systems are therefore necessary to facilitate timely intervention, ensuring that the developed protein-enriched meals are actually offered and effective. For this reason, the overall aim of our research project was to gain insight into the current state of undernutrition management in community-dwelling older adults in the Netherlands and explore the role of protein-enriched regular products as a supportive instrument in protein undernutrition management.In Study 1 (chapter 2) we explored the experiences of 22 Dutch nutrition and care professionals and researchers with undernutrition awareness, monitoring, and treatment among community-dwelling older adults. This qualitative study among, for example, dietitians, general practitioners, nurse practitioners, and home care nurses provided insight into the current bottlenecks within the existing undernutrition management guidelines. In these telephone interviews, these experts also discussed the current dietary behaviour problems of older adults and their impact on undernutrition risk. The experts’ experiences implied that undernutrition awareness is limited, among both older adults and care professionals. In addition, the interviewees were unclear about which professionals are responsible for monitoring and which monitoring procedures are preferred. The dietitians feel that they become involved too late, leading to decreased treatment effectiveness. In general, the interviewees desired more collaboration and a coherent and feasible allocation of responsibilities regarding undernutrition monitoring and treatment. This implied that the available guidelines on undernutrition management require more attention and facilitation.In the following mixed-methods study (chapter 3), with interviews, we qualitatively explored the dietary behaviour and undernutrition risk of 12 Dutch elderly meals-onwheels clients, one of the largest at-risk groups. We followed up on this information by quantifying the topics that emerged from the qualitative exploration of experienced bottlenecks in performing adequate dietary behaviour. For this, we used a survey among 333 meals-on-wheels clients. The interviews with elderly meals-on-wheels clients made clear that they have fixed and habitual eating patterns, while at the same time their appetite had decreased throughout the years. This was confirmed by the survey finding that regular portion size meals were perceived as too large by the oldest group aged over 75y. In addition, as the professionals suggested earlier, the interviewed elderly clients indeed showed limited awareness of undernutrition risk. Simultaneously, the survey showed that almost one in four elderly meals-on-wheels clients was undernourished. These findings led to the conclusion that staying close to the identified dietary habits may facilitate small yet effective modifications within these habits to prevent inadequate nutritional intake. Still, the limited awareness of undernutrition risk was expected to play a limiting role in whether clients believe they need dietary modifications. Consequently, informing them about this need could facilitate their motivation to implement modifications.After learning about the general dietary behaviour of these older adults, we used this information for Study 3 (chapter 4). We developed two kinds of protein-enriched readymade meals that are in line with the needs and preferences of older adults: one of regular size (450g) and one of reduced size (400g). We tested these meals in a lab setting in 120 community-dwelling older adults in a single-blind randomised crossover trial. One day a week at lunchtime, for four weeks, participants had to consume and evaluate a readymade meal. Overall, regardless of portion size, the protein-enriched meals led tohigher protein intakes in vital older adults in a lab setting during lunch. In this crossover study, the participants liked the protein-enriched meals and the regular meals equally. However, we did not find the expected lower ratings of satiety after the reduced-size meals, while one reduced-size enriched meal and another regular-size enriched meal led to higher ratings of subsequent satiety. This higher satiety in the enriched meals could lead to compensational behaviour on the remainder of the day.After establishing that the protein-enriched meals were effective and acceptable in the lab setting, we moved to the homes of older adults to test the meals in a longer-term study in Study 4 (chapter 5). In this double-blind randomised controlled trial of two weeks, we also included protein-enriched bread to assess whether both this bread and the meals could increase daily protein intake to 1.2g/kg/d in 42 community-dwelling older adults to reach optimal protein intake. We found that the enriched products again led to higher protein intakes and a high liking. The mean protein intake per day was 14.6g higher in the intervention group, which amounted to a protein intake of 1.25g/kg/d, compared with 0.99g/kg/d in the control group. In addition, the meals scored 7.7 out of 10, while the bread scored 7.8 out of 10, which both were comparable with their regular counterparts. Lastly, we found no negative effect of compensational behaviour throughout the day. These promising findings indicated that we achieved a good match between older adults’ needs and preferences regarding protein intake.In the general discussion of this thesis (chapter 6), we combined our learnings from the four studies to reflect on protein undernutrition management in community-dwelling older adults and the possible role of protein-enriched regular products. We have discussed a conceptual framework consisting of three wheels of protein undernutrition management. In the first wheel regarding awareness, we proposed that limited awareness of adequate nutrition and body composition forms the largest bottleneck in undernutrition management. When this awareness is generated among both older adults and professionals, it will benefit the second wheel of monitoring. Here, we argued that a policy and the actual facilitation of that policy are required for this monitoring to succeed. When the monitoring is performed adequately, in the third wheel, the appropriate treatment can be carried out. We discussed that personalisation and evaluation of this treatment are important conditions. All in all, the public health implications that we have discussed on the basis of our findings can be summarised by the three key messages that could help us ace in adequate protein undernutrition management: address awareness in both older adults and professionals, facilitate continuous collaboration between professionals, and offer protein-enriched products expediently.

Background Many older adults are at risk of undernutrition. Dietitians play a key role in the management and treatment of undernutrition, but older adults have difficulties to comply with dietetic recommendations. This qualitative study investigated which barriers older adults experience in adhering to treatment for undernutrition. Current dietetic practices and older adults’ experiences were studied, and the potential to use protein-enriched regular products in undernutrition treatment was investigated. Methods We interviewed 18 older adults who were under treatment for undernutrition, and 13 dietitians. Semi-structured interview guides were used, and all interviews were audiotaped and transcribed verbatim. The interviews were coded with qualitative analysis software NVivo9, followed by content analysis to formulate main themes. Results The interviews resulted in seven themes, which related to three main topics: barriers for treating undernutrition in older adults, current dietetic treatment, and new strategies to complement current treatment. Low awareness and a lack of knowledge regarding undernutrition, physical limitations, and loss of appetite were found to be major barriers for treating undernutrition in older adults. Dietitians said to focus mostly on increasing energy and protein intake by recommending the use of regular food products that fit the needs and habits of the patient, before prescribing oral nutritional supplements. Dietitians considered enriched regular products to be useful if they fit with the habits of older adults, the portion sizes were kept small, if products were easy to open and prepare, had good palatability, and were offered in a variety of taste and textures. Conclusions Results from the interviews suggest that undernutrition awareness is low among older adults and they lack knowledge on how to manage undernutrition despite efforts taken by dietitians. Enriched regular products could enable older adults to better adhere to undernutrition treatment, provided that these products meet the needs and eating habits of older adults. If protein-enriched food products can replace regular, low-protein variants, older adults do not need to consume more, but can adhere to their usual pattern while consuming more protein.

Background Undernutrition can negatively affect community-dwelling older adults’ health and quality of life. Undernutrition management guidelines have been developed in the Netherlands for the primary care setting, however, the application of these guidelines remain unsatisfactory. The current study therefore aims to explore qualitatively the experiences of Dutch nutrition and care professionals and researchers with undernutrition awareness, monitoring, and treatment among community-dwelling older adults. Methods We telephonically interviewed 22 Dutch nutrition and care professionals and researchers. Our semi-structured interview guide elicited answers that we audiotaped and transcribed verbatim. The interviews were coded using grounded theory and content analysis with the qualitative analysis software MAXQDA, after which the codes were categorized into themes. Results The interviews resulted in six themes relevant to the topics of interest: undernutrition awareness, monitoring, and treatment. These were: (1) adverse changes in nutrition behaviour; (2) limited undernutrition awareness; (3) unclear monitoring responsibilities and procedures; (4) lack of awareness, time, and priority as monitoring barriers; (5) lack of treatment personalization and justification; (6) lack of timely treatment implementation and evaluation. Conclusions The experts’ experiences imply that undernutrition awareness is limited, among both older adults and care professionals. In addition, the interviewees are unclear about which professionals are responsible for monitoring and which monitoring procedures are preferred. The dietitians feel that they become involved too late, leading to decreased treatment effectiveness. In general, the interviewees desire a coherent and feasible allocation of responsibilities regarding undernutrition monitoring and treatment. This implies that the available guidelines on undernutrition management require more attention and facilitation.

Background: Elderly patients admitted to the hospital after a stroke, joint replacement or trauma can recover at a geriatric rehabilitation setting. Ideally, geriatric rehabilitation considers the individually varying complexity of recovery, depending on for example degree of resilience, severity of multimorbidity, and extensiveness of social support system. During their rehabilitation, patients and their caregivers prepare for the patients’ return to home at the most optimal functional level. To accomplish this, it is imperative to centralize the rehabilitation around the personal needs and wishes of patients and caregivers. We as the Geriatric Rehabilitation Network – Patient in the Lead observed that this centralization is not common practice and the patient is rarely in the lead. An exploratory study among patients, caregivers, and healthcare providers confirmed our observations. We found three striking leads that should be pursued in geriatric rehabilitation: 1 Patients and caregivers strongly indicate a lack of a personal approach based on their needs and desires as well as a lack of continuous involvement and communication during their rehabilitation process; 2 Healthcare providers indicate a lack of alignment within and between disciplines and a lack of knowledge on the proper tools and measures based on the variety of complex disorders they encounter; and 3 Patients and caregivers indicate a suboptimal level of information management about transition and continuation of rehabilitation at home or another care setting. These three leads form the reason for our call for more personalised, efficient, and effective geriatric rehabilitation, with patients truly at its heart.Aims: The aim of this presentation is to inspire the audience to assign a central role to the patient. It is a well-known and common pitfall to overlook the patients as well as their caregivers: with our tools, measures, and experiences the audience can overcome this pitfall and improve geriatric rehabilitation from the beginning to the end by involving patients and caregivers continuously and effectively.Format: In this presentation we will discuss how to: 1 Tailor geriatric rehabilitation to the needs and desires of patients and caregivers, taking into account their diversity in past and current live events with effective skills in communication, Shared Decision Making, and Advance Care Planning; 2 Improve the mutual communication within and between the various disciplines involved in geriatric rehabilitation; and 3 Arrange optimal information management about transition and continuation of rehabilitation at home or another care setting.Target audience: We welcome any professional who wishes be more effective in geriatric rehabilitation, and evidently, anyone with personal experiences in geriatric rehabilitation, either as a patient or caregiver, as together we form a learning community.Learnings:Tools to effectively communicate with patients and caregivers to truly involve them in their own rehabilitation process.Tools to apply shared decision making and advance care planning in geriatric rehabilitation.Tools to measure and evaluate the progress of geriatric rehabilitation.

BackgroundDistinguishing hydronephrosis that requires surgical intervention is a clinical challenge. The aim of this study is to determine the level of urinary heat shock protein 70 (HSP70) in children who required surgery for ureteropelvic junction obstruction and its potential use as a biomarker for prediction of surgery in children with isolated unilateral hydronephrosis.MethodsThe data of 43 children with ureteropelvic junction obstruction who underwent pyeloplasty, 25 patients with non-obstructive dilation (NOD) and 30 healthy children (control group) were collected prospectively for this study. Preoperative and postoperative urinary HSP70/Cr levels were also analyzed in 30 children in the pyeloplasty group who had available follow-up information. HSP70 levels were assessed using ELISA.ResultsThe median age of the pyeloplasty group was 13 months (IQR 7–36 months), NOD group was 42.5 months (IQR 16–73) and it was 36 months (IQR 24–47.5) in the control group. The mean preoperative urinary HSP70/Cr was significantly higher in the pyeloplasty group when compared to controls as well as the NOD group (150.6 pg/mgCr vs. 65.0 pg/mgCr and vs. 64.7 pg/mgCr, p < 0.001 and p < 0.001, respectively). The urinary HSP70 levels significantly decreased in the postoperative period (151.5 vs 79.5, p < 0.001). Using the cutoff value of 94.7 pg/mgCr, the sensitivity and specificity of urinary HSP70 for predicting the risk of surgical intervention were 69.7% and 68%, respectively (AUC = 0.689).ConclusionUrinary HSP70 may be used as an adjunct tool to clinical parameters to identify patients that would require surgery due to ureteropelvic junction obstruction.

Purpose We aimed to investigate the urinary caspase-3 and cytochrome c levels in patients with unilateral antenatal hydronephrosis and to determine whether changes in urinary biomarker levels could be useful for both predicting the need for surgical intervention due to ureteropelvic junction obstruction (UPJO) and postoperative surgical success. Methods Sixty-five children with a history of unilateral antenatal hydronephrosis and postnatal anteroposterior diameter ≥ 10 mm were included in this prospective case–control study between January 2013 and December 2021. The obstruction group consisted of 33 patients (28 boys, 84.8%) who underwent open dismembered pyeloplasty due to UPJO. The non-obstructive dilatation (NOD) group consisted of 32 patients (27 boys, 84.4%) with stable or improving hydronephrosis and no significant reduction in ipsilateral split renal function during follow-up, whereas 34 healthy children were enrolled in the study as a control group. Urinary urinary caspase-3 and cytochrome c levels using ELISA were measured. Results The median preoperative urinary caspase-3 level was significantly higher in the obstruction group when compared to the NOD group (4.82 ng/mgCr vs. 2.61 ng/mgCr, p = 0.013) as well as the control group (4.82 ng/mgCr vs. 1.72 ng/mgCr, p = 0.002). In the postoperative period, urinary caspase-3 levels significantly decreased compared to preoperative measurements (4.82 ng/mgCr vs. 2.51 ng/mgCr, p = 0.006) and became similar to the control group (2.51 ng/mgCr vs. 1.72 ng/mgCr, p = 0.422). On the other hand, no significant differences were observed in urinary cytochrome c levels between the groups. All patients who underwent pyeloplasty achieved postoperative resolution in hydronephrosis and improved drainage on MAG-3, so none of the patients required re-do pyeloplasty. Postoperative decrease in caspase-3 level was found to be compatible with adequate urine drainage on MAG-3 scan. The cut-off value of urinary caspase-3 to predict patients requiring pyeloplasty was found to be 3.31 ng/mg creatinine with 63.6% sensitivity, 62.5% specificity (AUC = 0.679). In the multivariable analysis, urinary caspase-3 level (OR: 1.653, p = 0.019), anteroposterior pelvic diameter (OR: 1.401, p = 0.001), and split renal function on MAG-3 (OR: 1.277, p = 0.011) were found to be independent factors in determining patients who require surgery. Conclusion Based on our preliminary findings, urinary caspase-3 levels could be a useful biomarker not only for predicting the need for surgical intervention but also for determining the postoperative surgical success in children with UPJO.