SYMPTOM COMPLEXITY IN FRAIL OLDER ADULTS
Authors:   , Rutten Jeanine Johanna Suzanna 
Published: January 2025

This thesis focuses on two research projects: one on antibiotic prescribing for urinary tract infections (UTIs) in nursing home (NH) residents, and the other on COVID-19 in the same population.

Part 1:
Antibiotic overprescribing is common in NH, particularly for suspected UTIs. Diagnosing UTI in frail older adults in NHs is challenging, as they may have difficulty expressing symptoms. Additionally, standard urine tests are not suitable for diagnosing UTIs in frail older adults as they may have bacteria in their urine without having an infection. Physicians often prescribe antibiotics to be ‘better safe than sorry’. This practice contributes to the development of antibiotic resistance.

Chapter 2 describes the ANNA study, a cRCT conducted in 16 Dutch NHs from March 2019 to March 2020. The intervention group received a decision tool integrated into the EHR and supportive interventions. The control group provided usual care. The primary outcome was appropriate antibiotic prescribing at the day of diagnosis, and secondary outcomes included UT-related complications, hospitalization, mortality, and overall antibiotic prescriptions.

Chapter 3 presents the study results, showing a 13% difference in appropriate antibiotic prescribing in favor of the intervention group (62% vs. 49%). However, this difference was not statistically significant. The intervention group did show a significant reduction in total antibiotic prescriptions, leading to the conclusion that while no significant difference was found in appropriate prescribing, the intervention might still be effective.

Chapter 4 discusses the process evaluation. It found that internal validity was limited by control group physicians' participation in non-study-related activities regarding UTIs, which may explain the lack of a significant difference in appropriate antibiotic prescribing between the groups. It recommends improving the feasibility of the intervention for residents with dementia and urinary incontinence.

Chapter 5 introduces the OKKO study, which aimed to improve UTI diagnosis in NH residents with dementia. The study showed that assessing UTI-related signs and symptoms in residents with dementia becomes more difficult as dementia severity increases. The developed observation checklists may improve UTI diagnosis in NH residents with dementia.

Chapter 6 explores the urineSTICKS study, which assessed the use of urine dipstick tests in NH residents. Among residents without an indwelling catheter who had a urine dipstick test, 45% of the tests were not in accordance with guidelines. Recommendations include increasing nursing staff’s knowledge of appropriate test use and involving nursing staff in the de-implementation process.

Part 2:

At the beginning of the COVID-19 pandemic, NHs were facing a disaster with little awareness from the outside world. To raise awareness and gain more insight into the ‘silent disaster’ in nursing homes, a registration system was set up in the electronic health record.

Chapter 7 describes a cohort study involving 1,538 residents with clinically suspected COVID-19. The study found that residents with confirmed COVID-19 were three times more likely to die within 30 days compared to those without. Higher mortality was associated with male gender, dementia, and Parkinson’s disease. The study emphasized the importance of testing to distinguish COVID-19 from other illnesses.

Chapter 8 compares 30-day mortality rates between residents with and without COVID-19. Residents with COVID-19 had an 18-fold higher risk of death, with dementia and Parkinson’s disease significantly increasing the risk of death among those infected. Male gender was not a unique risk factor for death among those with COVID-19, as it was also a risk factor for death in the broader NH population.

Conclusion
The findings of the ANNA, OKKO, and urineSTICKS studies contribute to more accurate UTI diagnoses in NHs, which can reduce inappropriate antibiotic prescribing. The COVID-19 registration system raised awareness of the issue and facilitated the development of appropriate policy responses.