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Little is known about the raising number of specialized units for patients with dementia and very severe challenging behavior in the Netherlands. This study describes organizational and treatment characteristics of a sample of these units.
The organizational and treatment characteristics were studied with digital questionnaires completed by the unit managers, interviews with the main physician(s) and observation of the physical environment. The questionnaire consisted of questions about general patient characteristics, unit characteristics and staff characteristics. Furthermore, an interview was held with the main/treating physician often together with another physician or psychologist. The interview guide consisted of questions about admission criteria, the role of staff involved and the treatment process.
Thirteen units participated. Five units were part of a mental health (MH) institution, seven units were part of a nursing home (NH) organization and one unit was a cooperation of MH and NH. Unit sizes ranged from 10 to 28 places. Ten of thirteen units started in 2010 or later. The age of patients admitted was estimated at 75 years. The percentage of involuntary admitted patients was 53% at MH-units and 18% at NH-units. Unit managers mentioned that due to a difference in reimbursement between MH and NH units had difficulty providing the specialized care. Another problem managers faced was recruiting nursing staff. Units strived for expertise in general staffing from both MH and NH. The education level of the nursing staff was comparable between MH and NH. At every unit a physician with background in elderly care medicine or geriatrics and a psychiatrist was involved. Interviewees stressed the role of the nursing staff in the treatment. They were key in providing the care and treatment that, since the main goal of interventions is treatment of and coping with challenging behavior.
The main finding of this study is that units caring for patients with dementia and challenging behavior, despite barriers in regulations and staffing shortage, search for combining expertise from nursing home care and psychiatry in their treatment.
Frailty is a common clinical syndrome in older adults that carries an increased risk for poor health outcomes. Early identification of frailty may help optimizing quality of care. Fried's frailty criteria are often used as the gold standard of frailty. However, it takes too much time and the availability of a hand grip strength meter to measure these criteria in daily practice. Screening instruments for frailty such as the Groningen Frailty Indicator (GFI) and the Tilburg Frailty Indicator (TFI), are available. However, it is not yet certain whether the usual cut-off values are applicable to older psychiatric patients.
To determine internal consistency, sensitivity, specificity and area under the curve (AUC) of the receiver operating characteristic-curve (ROC- curve) of the GFI and TFI using validated cut-off values, and to determine the optimal cut-off value in older psychiatric patients.
Baseline data of an ongoing prospective cohort study were used. In this study GFI, TFI and Fried-criteria were determined in hospitalized and non-hospitalized psychiatric patients over 65 years old.
A total of 145 participants were enrolled, 90 of which were hospitalized and 55 were non-hospitalized. Median age of participants was 75.2 (SD =7) years, 108 were female. Prevalence of frailty according to Fried-criteria was 29.7%. Internal consistency (Cronbach's alpha) of the GFI was 0.76 and TFI = 0.75. Using the validated cut-off value and the Fried- criteria as reference, sensitivity of the GFI (≥4) was 0.95 (95% CI 0.83 - 0.99) and specificity 0.27 (95%CI 0.19 - 0.37). Sensitivity of the TFI (≥5) was 0.98 (95% CI 0.86 - 1.00) and specificity 0.31 (95% CI 0.23 - 0.41). The optimum cut-off value for both the GFI and TFI was ≥8. The AUC of the ROC-curve of GFI and TFI were 0.82 (95% CI 0.75 - 0.90) and 0.79 (95% CI 0.72 - 0.87), respectively.
We found an acceptable internal consistency and AUC of both the GFI and the TFI in older psychiatric patients. Increasing the cut-off values of both GFI and TFI seems necessary to lower the amount of false positives in this population.
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