Geriatrics in primary care

The research within our LUMC departments is conducted within departmental research programmes. The research programme below is embedded within the department of Public Health and Primary Care.

Aim and focus

The overall aim of the research program ‘geriatrics in primary care’ is to improve health, functioning and quality of life for all older persons outside the hospital by building on scientific knowledge and evidence for (the organization of) medical care. Improvement of health, quality of life and daily functioning of older people are the main aims of all our research, with perspectives and needs of older people as a guide.
As our inspiration, we use gaps of knowledge in epidemiology of diseases and syndromes, their diagnosis and optimal treatment in old age, but also on aetiology and possibilities for prevention of consequences of diseases. We have a focus on personal patient preferences/goals, and on the consequences of health problems for everyday activities and participation in society.  We perform observational research (qualitative as well as quantitative) combined with intervention studies and implementation research to cover these gaps of knowledge. Important emphasis is put on the search for differences in aetiology and subsequent different diagnosis and treatment possibilities in older people compared to younger age-groups, and identifying those older people who are in real need for pro-active care, cure or prevention. Concerning the latter, we collaborate intensively with the second department’s research program PrePoD, in which risk assessment and the possibilities of a population approach are further explored on other relevant groups as well (Population Health Management, LUMC Campus The Hague, prof.dr M. Numans).

To contribute to health, quality of life and independence in daily functioning of older persons, we focus our research on
1) content of medical care : improvement of etiologic understanding, diagnosis, treatment and prognosis of frequently occurring diseases and combinations of diseases and syndromes that influence everyday lives of older persons.
2) organisation of medical care: improvement of organisation of medical care to optimise health outcomes for older persons, taking into account the variety in level of vitality.

Content of medical care  

For some high-prevalent diseases and health complaints with impact on lives of older persons, we study more in-depth aetiology and possibilities for prevention and treatment, for example:

  • ‘Cardiovascular risk management in old age’. We aim to develop evidence based strategies for cardiovascular risk prevention in old age. We started to study which older people are at risk for cardiovascular diseases after age 85 years and to investigate whether this is generalizable to the younger spectrum of older people. We aim to develop optimal treatment strategies for those older persons who are at risk. We do not limit to primary prevention, but we also study the optimal selection and treatment of those at risk after a cardiovascular event (secondary prevention). 
  • Subclinical hypothyroidism is a high prevalent disorder in old age. However, it is not clear what the risks are and whether treatment would benefit older persons. To study the risks of thyroid dysfunction, we founded the ‘International Thyroid Collaboration’ in which around 20 international observational cohort studies collaborate to aggregate all available data on the risks of subclinical hypothyroidism. In addition, we perform the TRUST trial (2013-2017), a placebo-controlled European trial to test the effectiveness of thyroxin treatment in older persons with subclinical hypothyroidism. In line we perform the Dutch IEMO thyroid trial, specially developed for participants aged 80 years and over.
  • Clinical infections (e.g. urinary tract infections and respiratory tract infections) frequently occur in old age and influence daily functioning negatively. We study the effects of clinical infections and possible preventive options. CRANBERRY is a randomised controlled trial to study the costs and effects of use of cranberry extract to prevent clinical urinary tract infections and subsequent disability in nursing home patients.
  • Quality of life in Dementia; we study both physical determinants of qualify of life in dementia, such as pain, as psychosocial determinants . Multiple studies of our group have given offered better insight into the why and how of poor assessment and under treatment of pain in patients with dementia. Many of these studies are performed in a European network, based on a EU-COST action (2011-2016)
  • We study the prevalence and incidence of disability in older persons within different populations, ranging from community-dwelling older persons to nursing home residents. In addition, we study predictors of decline, and etiological mechanisms of decline. To  this end, we employ existing data from cohorts of older people (Leiden 85-plus Study, PROSPER study, TRUST study, Rotterdam Study, AWBZ-rehabilitation, SINGER, The Hague Hip Fracture Cohort, COOGER), data collected in our trials (e.g. ISCOPE, PROMODE, FIT-HIP, Q-PID) and routine primary care population cohorts (RNUH-LEO and ELAN datawarehouse).

Organisation of medical care  
  • Prevention in old age triggers to think about new possibilities, evidence for prevention, appropriateness of screening, ethical and legal questions. 
  • Pro-active integrated care for older persons in primary care. Since professionals and policy makers feel integrated care is the optimal type of care for older persons with complex problems, we aim to build the scientific evidence. In ISCOPE, a randomised trial investigating the costs and effects of a simple programmatic monitoring system for complex problems in older persons in primary care is tested, combined with an integrated care-intervention by the general practitioner. In residential homes, we performed an implementation study (MOVIT) in which the medical care in 42 regional residential homes is reorganised towards integrated care, and allow for innovation and improving the quality of care. In SINGER, nursing homes have improved their coordination of care and  care chain communication for patients in geriatric rehabilitation.
  • End-of-life care and quality of life for older persons with dementia. Quality of life is a main focus of our research into the care for people with dementia, including at the end of life. This theme is highly relevant to an aging society and speaks to fears and concerns about the quality of life of people with dementia, a group at increased risk through being dependent upon us to offer evidence-based interventions and high-quality care. We started this new research theme in 2016. 
  • Recognising the benefits for people with chronic-progressive disease, palliative care is increasingly conceptualised as applicable to a broader spectrum of diseases than cancer only. Palliative care is also applied earlier in the course of the disease, which is especially relevant for dementia in view of the patient’s inevitable cognitive decline and the importance of advance care planning, and in view of a variable illness trajectory in which the terminal phase is difficult to predict. Palliative care is anticipatory and multidisciplinary by nature and funding for new projects acquired in 2016 reflect this. The Palliantie “SigMa” project uses a participatory action research design and empowers nursing staff to select and use tools to identify changing needs and the terminal phase in nursing home residents and communicate findings in the multidisciplinary team. In Q-PID, a randomized cross-over trial is performed, in which patients with dementia with low quality of life scores are prescribed paracetamol for 6 weeks.
  • Following the STA OP! trial that decreases pain and improves behaviour in nursing home residents with dementia, Namaste Care Family, a project in collaboration with VUmc, trials an intervention based on palliative and person-centred approaches. It aims to improve quality of life of people with advanced dementia and to improve family caregivers’ experiences. Another Palliantie project in collaboration with the LUMC “Expertisecentrum Palliatieve Zorg” develops a guide for practitioners, and a patient version, to improve bereavement care. It is not specific to dementia, but targets institutions including nursing homes and hospitals. The research theme typically involves extensive international and national collaboration with practice and researchers who focus on the same or neighbouring areas. It also includes research on the quality of the research itself, for example through developing measurement instruments for more accurate observation of pain in people with dementia within the PAIC network, and through leading a Cochrane review.
  • ‘Geriatric Rehabilitation’. To optimise the recovery of older persons after medical events such as stroke and hip fracture, we study the process and outcomes of geriatric rehabilitation in rehabilitation-wards in nursing homes and at home. After analysis of observational studies of the type and amount of rehabilitation, characteristics of the patient and functional outcomes, intervention studies are developed. For instance, a multimodal intervention for fear of falling is tested in a randomized controlled trial in several rehabilitation wards of nursing homes.  In collaboration with MCH hospital in the Hague, and the Campus The Hague, a large longitudinal study on the outcomes of hip fracture is started in 2017. Also, a study on the effect of a special care program for post exacerbation COPD patients started in 2015 and will end in 2018.
  • ‘Optimal pharmacologic care for older people’. Although inappropriate medication use could lead to negative effects, medication reviews are not needed for all older people. In this subline we are in search for a more targeted intervention to perform medication review. For which patients this is beneficial, which outcomes will be affected and what is the best way to do a medication review?

Position in international context

Our research group is one of the few that study geriatrics in primary care. We have good international collaboration with Katholieke Universiteit Leuven (prof. dr B. Aertgeerts), Université catolique de Louvain (prof. J Degryse), Newcastle University (prof. dr T. Kirkwood), University of Auckland (Prof. N. Kerse). Within the Thyroid Studies Collaboration we perform meta-analyses and the TRUST/IEMO Study. Within the TULIP-consortium (University of Auckland, Newcastle University, University of Tokyo) we perform longitudinal analyses in cohorts of older people.
Further extended collaboration with: Johann Wolfgang Goethe University Frankfurt (Dr. C. Muth), Brisbane University, Australia (Prof. M. van Driel), University of Bergen (Prof Dr. B. Husebo), Achterberg is visiting professor at the University of Bergen. Within the European Association for Palliative Care (EAPC) we are a very active member and we participate to the FP7 EU project PACE. Achterberg was the vice-chair of the EU-COST action TD1005 Pain in cognitive impairment (2011-2016).

International positions and grants

  • Dr J van der Steen received and ERC consolidator grant (2017)
  • Prof.dr W.P. Achterberg is appointed as invited professor in Bergen (Norway).
  • Gussekloo is since 2015 member of the International Scientific Advisory board of National Challenge Ageing Well, New Zealand (international chair from 2017 onwards)
  • Achterberg is vice-chair of Eu COST-Action TD1005, PAIC
  • Gussekloo member of Joint Programming Europa: ‘more years better life’ (2015-2017) 

Content / highlights / achievements

We will give in written ‘narratives’ a description of topics in which our research group is scientifically and clinically leading (inter)nationally. These are typical examples of our focus of research      

Content of medical care 

Management of Subclinical hypothyroidism
Subclinical thyroid disorders are frequently found in older persons, often by routine blood testing. Internationally, there is a large difference in insights towards the need for treatment. Since Gussekloo published that hypothyroidism was associated with longer life without negative effects (Leiden 85-plus Study, JAMA 2004), our research group is strongly involved in collaborations to come to evidence-based choices on treatment. Within the International Thyroid Association, started by Gussekloo and Rodondi, almost all large observational cohort studies collaborate to investigate the various risks of thyroid disorders by Individual Patient Data analysis. These analyses gave and will give new insights in the risks of subclinical thyroid disorders. Until now, all were published in high ranking scientific journals (JAMA, JAMA Internal Medicine, Circulation). In addition, we are performing a double-blinded placebo controlled trial to study the effect of thyroxin treatment in older persons with subclinical hypothyroidism. This is financed by KP7, European Union (TRUST, Gussekloo member steering committee and Dutch PI), and ZonMW (IEMO thyroid study). The results of this TRUST trial have been published in June 217 in NEJM: treatment with thyroxine was not clinically beneficial for older persons with subclinical hypothyroidism. This combination of observational and RCT evidence will lead to a strong and hopefully definitive answer on the need for treatment of this disorder in old age. Our next step will be to study whether patients with current thyroxine treatment could stop this treatment. A grant proposal is currently being reviewed.  

Quality of life in dementia
Results of our studies have led to the national guideline ‘Pain in vulnerable elderly’ (chaired by Achterberg). Also the STA OP trial has been implemented in many nursing homes, and has been proven to be effective on both pain and behavioral problems in dementia. The effect article on pain has been awarded the ‘best article on palliative care in the Netherlands’ in 2017, and STA OP intervention has been selected by Vilans as ‘’Good Practice’ project.

Focus organisation of medical care

Organisation of primary care for older persons
Since the number of older persons is increasing, and the expectations of GPs in their care for older persons are increasing, this is a very important societal challenge. Older persons, professionals and policy makers have optimistic expectations of integrated care for older persons with complex care needs, especially when it is pro-active in nature. Within the National Programme for Elderly Care (since 2008), we had the opportunity to test new models of care. Specific topics were the combination of screening and integrated care in general practice (ISCOPE) and optimal organisation of medical care in homes for the elderly (MOVIT). Blom and Gussekloo are leading a Dutch initiative of combining all available evidence on pro-active integrated care.

Gussekloo  and other senior staff members are strongly involved in various Dutch committees of professionals and/or policy makers on this societal emerging topic in primary care (chair NHG committee ‘Primary Care for older persons’ (2014-2017), member KNMG ‘sterke zorg voor kwetsbare ouderen’ (2012-2016), chair NFU committee ‘elderly care’ (since 2014). In postgraduate education, we contribute to optimised primary care for older persons. Not only by organising and lecturing in short courses (Boerhaave, Wenckenbach, etc), but also by organising 2-years executive educational tracks (‘kaderopleidingen’) for GPs and nursing home doctors who are frontrunners in the field, on medical and organisational aspects of care for older persons in primary care (130 GPs and 30 NHD graduated). These graduated doctors take, for example, the lead in regional projects in care for older persons. They are members of LAEGO (National network of ‘kaderhuisartsen ouderengeneeskunde’). By our strong combination of research, policy work and educational activities of senior staff members, our Leiden ageing research group is leading in the innovation of primary care for older persons in the Netherlands.

Geriatric Rehabilitation
Older people who have had a stroke or hip fracture need restorative care, and because of the demographic changes, the clinical and research field of geriatric rehabilitation has emerged. It is a rapidly growing clinical urgency, but it is internationally a relatively young research area. (Inter)nationally Achterberg is a leading researcher on this theme. Our research group has 8 PhD students on this topic at the moment, which makes it one of the largest dedicated  groups internationally. This has resulted in several (invited) articles, lectures and symposia in the USA and Europe. An article in the most prestigious Long term care journal (JAMDA) by our group was honoured with an editorial, stressing the importance of our work. Next to scientific output on this topic,  Achterberg is also involved in almost all Dutch committees of professionals and/or policy makers on this societal emerging topic.

At MCH Bronovo Hospital we started a large longitudinal Hip Fracture Cohort study (650 patients each year), and have received funding for three researchers: one with the focus on biology/surgery, one with the focus on rehabilitation therapy, and one with the focus on the relation with primary care. This is very important, as the prognosis of hip fracture is very poor, and has not improved in the last 30 years!

The results of the thesis of Visschedijk (2016) and Holstege (2017) have led directly to improvements in the care of the nursing homes. We have developed a clinimetrical set of instruments, that will be implemented in the nursing homes of South Holland in 2017, and planned nationally for 2018. This set will be used for benchmarking, research and tested for PROM use, with a Value Based Health care approach. Another promising development is the start of the a large longitudinal Hip Fracture Cohort study (650 patients each year) at HMC-plus Bronovo. We have already received funding for three researchers: one with the focus on biology/surgery, one with the focus on rehabilitation therapy, and one with the focus on the relation with primary care. This is very important, as the prognosis of hip fracture is very poor, and has not improved in the last 30 years!

Future themes

For coming years, we will continue to contribute to health, quality of life and independence in daily functioning of older persons by adding research. We focus our research on

  • Content of medical care: improvement of etiologic understanding, diagnosis, treatment and prognosis of frequently occurring diseases and combinations of diseases and syndromes that influence everyday lives of older persons.
  • Organisation of medical care: improvement of organisation of medical care to optimise health outcomes for older persons, taking into account the variety in level of vitality. 
By collaboration within the LUMC, in the region, national and international we will have a broad reach in partners and content.

Cohesion within LUMC

In general, we always assure methodological and content-specific specialist input from LUMC departments in our research projects. We seek collaboration with LUMC partners in basic and clinical research. There is a strong collaboration with the departments of Gerontology and Geriatrics (Mooijaart, Blauw), Psychiatry (van der Mast), Medical decision making (van den Hout), Clinical epidemiology & Medical statistics (LeCessie), and Cardiology (Jukema), Centre of Expertise Palliative Care (van der Linden). 

Our research group participates in the LUMC Generic Research Profiles  ‘Ageing’ and ‘Innovation in Health and Quality of Care’. We also participate in the Leiden University research profile area Health Prevention and the Human Lifecycle. In the context of the first profile area, regular research meetings with clinical and basic sciences have started up. Gussekloo and Achterberg actively participate in the management of this profile area. We expect possibilities for collaboration within the profile areas to grow over the next years, especially when we will be able to contribute to the newly established LUMC societal outreach area “Population Health” and the LUMC Campus The Hague Population Health Management program.