Research of the medical care for the older people

An important question, with a view toward the increasing proportion of elderly citizens in the Dutch population, is how the quality of the medical care for the elderly can best be guaranteed. In 2004, with this question as the point of departure, the Minister of Health, Welfare and Sport asked the Advisory Council on Health Research (RGO) to indicate how research might help to answer this question. The Council was asked to include, in its recommendation, a clear indication as to how the existing scientific potential and insights could be used and applied more effectively in geriatric medical care.

In order to gain an impression of the research in our country, the Council first made an inventory of the main topics in both the current and the completed research programmes in the field of aging and the care of the elderly. This inventory revealed that a variety of government-subsidised research programmes have been developed in this field during the past years. It is the Council’s opinion that, as a result, our country have a number of excellent cohorts directed at geriatric research but biomedical research is now also embedded sufficiently firmly in academic research.

The same does not hold true of clinical research and research in the area of healthcare organisation. There is still little research of this type, and most of it is scattered over several, often smaller, programmes and research groups. A contributing factor here is that little clinical research on the elderly is generally carried out, due partly to the fact that the elderly are often excluded from research programmes for reasons of methodology.

To enable a well-founded selection from the research in the field of clinical care, the Council then turned its attention to the content of the geriatric care. There are three points on which research could deliver a substantial contribution:

Little is yet known about the growing group of frail elderly with comorbid problems. There is insufficient information on how the depletion of the mental and physical reserves in old age leads to frailty, as well as on how this process could be prevented, slowed down or stopped. Moreover, very little is known about the relation between frailty, comorbidity (having more than one disease at the same time), and the development of functional impairment, as well as about the possible ways to intervene in this process.

A second point that deserves additional attention with a view toward strengthening geriatric care is the creation of a scientific basis for the guidelines for medical and nursing care. Because the elderly are often excluded from clinical trials, many of the guidelines for the elderly have insufficient validity. Moreover, many elderly patients suffer from more than one disease but the guidelines for the treatment of these different diseases are sometimes mutually incompatible or difficult to reconcile.

A third point is healthcare organisation. During the past few years, a number of experiments have been carried out in order to improve the coordination of geriatric care and bring it more into line with the needs of the elderly. These experiments, as well as more recent developments such as health centres for the elderly and the collaboration between first-line and second-line medical care, should be thoroughly evaluated in a scientific manner before being applied on a wide scale. The possibilities and limits of volunteer aid also deserve further investigation in this connection.

The Council assumes that research and practice will be brought into greater harmony if the people engaged in research and practical healthcare are more closely involved in each other’s work. For this reason, the Committee urges that the research efforts be concentrated in those areas where it has already been demonstrated that researchers and healthcare practitioners can be brought together into a single line of investigation. There are already a number of different examples of this in our country.

The Council also urges that the research efforts be concentrated on a limited number of topics so that the research in these areas can be developed effectively.
On the above grounds, the Council has formulated the following four recommendations:

1. Include elderly patients in ‘regular’ clinical trials wherever possible.
2. Stimulate and support the preparedness to undertake research and innovation.
3. Concentrate the research on the following three areas:
   - the medical care of frail patients with multiple problems;
   - guidelines for diseases in the elderly;
   - healthcare organisation.
4. Concentrate the research in cooperative associations between healthcare practitioners and research institutions.

It is the Council’s opinion that these four recommendations could be effectuated jointly in a programme that, like other programmes of the Netherlands Organisation for Health Research and Development, works towards the creation of consortia. In such consortia, research institutions and institutions for healthcare must work together around a specific research topic with a clear understanding as to the institutions that will take part in the consortium and their responsibilities, the topic to be investigated, the distribution of the research results, etc. A number of the already existing research networks could serve as a point of departure here.

Committee