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To the Editor:

In western society, the percentage of elderly people in the population has increased dramatically and is likely to increase more in the decades to come. In the year 2000, 13.4% of the general population in The Netherlands was older than 65 years, and this percentage will increase to 23.3% in 2025 (1). The shift toward an older population will place a heavy burden on the health care system, because health problems in the elderly are often complex and expensive to treat. Existing special care for the elderly is most often focused on patients with cognitive problems (2). However, the most frequently reported health problems in the elderly are related to the locomotor system (3, 4). Due to a low incidence of rheumatic diseases in an average practice, the general practitioner may have difficulties in diagnosing and treating rheumatic conditions (5). The presented symptoms may be the result of a wide range of endocrine, metabolic, traumatic, and psychological conditions, and the clinical picture of some rheumatologic disorders is different in elderly patients as compared with younger patients (6, 7). After proper diagnosis, treatment may be limited in older patients. For instance, older people seem to be more vulnerable to side effects of medication (8) and are often unable to undergo complex treatment due to impaired motor and cognitive function (9). Finally, in elderly patients the ability to cope with health related problems is often impaired by a decrease in informal care and income, an increase in loneliness (6), and higher vulnerability to depression (3). It has been suggested, therefore, that there is a need for specialized services aimed at improving health care for the elderly with rheumatic conditions (9).

At the Sint Maartenskliniek in Nijmegen, The Netherlands, such a specialized service has been introduced: the gerontorheumatologic outpatient service. This service was developed to support the general practitioner in diagnosing and treating elderly patients with locomotor problems. The aim of the service is to prevent unnecessary impairment and disability, preserve independence in activities of daily life, improve mobility, decrease pain, improve care quality, and reduce care quantity. General practitioners refer patients older than 75 years with locomotor problems to the gerontorheumatologic outpatient service. Patients are scheduled for a visit to the rheumatologist and a specialized nurse practitioner. Directly following the dual appointment, the rheumatologist and nurse decide on a course of action. Three actions are possible: no further treatment in the hospital but advice to the general practitioner related to diagnosis and treatment, additional treatment in primary care, and multidisciplinary treatment in the hospital. Patients are informed of the examination findings and treatment options are discussed. The referring general practitioner is informed about the results of the patient examination and treatment advice.

Data from the first 100 patients are reported here. The average age of the patients was 78 years, range 75–91 years. Patients were predominantly female (85%). In the sample, 45% of the patients lived together with their partner, 55% lived alone. Most patients lived independently (86%), whereas 14 patients lived in a senior citizens home.

Table 1 illustrates the complexity of problems in this sample. Multiple diagnoses were observed in most of these elderly patients. A total of 174 rheumatologic diagnoses were set in 100 patients, with more than 1 diagnosis observed in 55 patients. Most predominant was osteoarthritis, which was found in more than half of the patients, often in combination with another diagnosis. Furthermore, there was a high incidence of nonrheumatologic conditions in this population. Only 25 patients were free of nonrheumatologic chronic conditions. In 33 patients, 1 nonrheumatologic condition was found and in 22 patients there were 2. No patients with substantial cognitive functional impairments (for instance as in dementia) were referred to the service. Therefore it is concluded that this new service reached the designated target group: the elderly patient with locomotor problems.

Table 1. Frequencies of rheumatologic diagnoses and comorbidity (n = 100)
RheumatologicNo.NonrheumatologicNo.
  • *

    COPD = chronic obstructive pulmonary disease.

Osteoarthritis60Cardiovascular disease36
Spondylosis39Hypertension29
Crystal-induced arthritis15Diabetes mellitus20
Osteoporosis14Cerebrovascular disease14
Rheumatoid arthritis13Gastrointestinal disease14
Arthritis, other12Pulmonary COPD*11
Shoulder problems10Hormonal disease9
Soft-tissue disorders5Neurologic disorder3
Polymyalgia rheumatica4Others4
Others2  

Patient functioning was assessed using the Modified Barthel's Index (MBI) (10). The MBI measures independence of the patient in 15 activities of daily life independent of diagnosis. There was a large variety of functional independence within this group of patients. Complete independence was observed in 33 patients (maximum MBI score). Another 33% showed relatively high independence (MBI scores ranging from 88 to 99 points). Finally, another third of the patients showed marked dependence on a series of activities of daily living (50–87 points).

Additional actions were based on the rheumatologist's and the nurse practitioner's findings in each individual patient. Most patients (n = 59) were referred back to the general practitioner. In these cases, the practitioner received additional diagnosis and treatment advice shortly after the visit to the hospital. An additional 10 patients were referred back to the general practitioner after 1–3 additional visits at the outpatient clinic. The remaining 31 patients received further treatment by the rheumatologist, 19 of them received regular outpatient treatment by the rheumatologist alone. In 12 patients, the problems were deemed serious enough to warrant multidisciplinary treatment, either ambulatory, clinical, or surgical. The rheumatologist prescribed medication for 82 patients. Physical therapy was prescribed for 17 patients and occupational therapy for 3.

Patients were contacted again by mail 6 months after the gerontorheumatologic service was ended to participate in a patient evaluation. Of the initial 100 patients, 81 completed and returned the questionnaire. Patients were very positive about the content of the service. Most patients (86%) indicated that they had used the information and advice given during the gerontorheumatologic service, and 75% indicated that the service had given them new information. Most patients (89%) would recommend the service to other patients of their age with similar problems, and 92% of the patients gave an overall positive evaluation. Similar levels of patient satisfaction are very common in the evaluation of treatment services. Therefore, the evaluation by the general practitioner is a more reliable measure. In The Netherlands, general practitioners are in close contact with the patient and are well aware of the patient's situation. All 77 referring practitioners were contacted by mail 6 months after they referred a patient to the gerontorheumatologic service. A short questionnaire was sent by which they could evaluate the content of the service. Of these 77 practitioners, 53 returned the mailed questionnaire (response rate 69%). Of the responding general practitioners, 83% thought that the additional diagnostics given by the rheumatologist were relevant in treating the patient. They felt confident that the service had a positive effect on the patient (82%) by reducing pain, improving activities of daily life, or improving mobility. Consequently, 89% of the referring practitioners evaluated the service as an important and positive initiative, and would recommend it to their colleagues.

These preliminary results underline the importance of special care for the elderly with locomotor problems. The high incidence of multiple diagnoses underlines the complexity of physical problems in this sample. Given the complex diagnostics, it is remarkable that a large number of patients are able to maintain their independence at an advanced age. However, a small group of patients in this sample experience severe dependence on others in their daily activities. The rheumatologist was able to give the general practitioner useful advise regarding this group of patients. The general practitioners who returned the questionnaire gave a positive evaluation of the gerontorheumatologic outpatient service. The new service therefore reached its goal, because it helped the general practitioner diagnose and treat elderly patients with locomotor problems.

More studies are needed to determine the usefulness and effectiveness of this new service. For instance, no attempt was made to determine the patients' compliance with the advice, or whether the advice had the desired effects. Furthermore, additional information on the patients' social and psychological function should be gathered, as well as information about the informal care and income of the patient. Nonetheless, the service is evaluated as positive by both the patient and the referring general practitioner. These findings suggest that the service may help solve the problems of an aging society. Many patients can be treated very well, and the little effort invested in this new service might help the patient maintain independence.

  • 1
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  • 2
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W. van Lankveld PhD*, M. Franssen MD, PhD†, M. van Kessel PhD†, L. van de Putte MD, PhD‡, * Sint Maartenskliniek Research, Nijmegen, The Netherlands, † Sint Maartenskliniek, Nijmegen, The Netherlands, ‡ University Hospital of Nijmegen, University of Nijmegen.