Priorities of elderly dizzy patients in general practice. Findings and psychometric properties of the"Dizziness Needs Assessment" (DiNA).

BACKGROUND: Dizziness as a geriatric syndrome needs to be assessed using a multi-dimensional, patient-centred approach in addition to a disease-orientated strategy. The aim of the study was to determine the priorities of elderly patients by a specific needs questionnaire, the"Dizziness Needs Assessment" (DiNA), and to evaluate its psychometric properties. METHODS: General practitioners (GPs) distributed questionnaires containing the DiNA as well as the Patients' Intentions Questionnaire (PIQ) to patients aged at least 65 years and suffering from dizziness. Items of both questionnaires were analysed by frequencies, means and rank correlations. Factor structure was explored by principal component analysis. RESULTS: A total of n=123 patients (mean age 76 years, 73% women) had suffered from dizziness on average for more than 3 years (57% chronic, i.e. >6 months). Knowing the cause of the dizziness was rated as very important by patients, and about half of them wished that their doctor would make more effort to investigate this. Among other differences, chronically dizzy patients ranked the risk of falling significantly higher than those with acute dizziness. Factor analysis revealed four subscales: "handicap and mobility" showed a very good reliability of 0.77 (Cronbach's α), indicating a "trait", whereas the other subscales rather indicated "state" characteristics. Validation coefficients showed that PIQ assesses general patient needs compared to the more specific dizziness-related needs revealed by the DiNA. CONCLUSION: The DiNA proved to be a valuable instrument to assess the specific priorities of elderly patients suffering from dizziness. Regarding the limited therapy options for dizziness in old age, a doctor-guided shift of patients' attention from causes to symptom-related implications could be a promising approach.

[Early diagnosis and early treatment of cognitive disorders: a study of geriatric screening of an unselected patient population in general practice]. / Früherkennung und Frühbehandlung von kognitiven Funktionseinbussen: eine Studie über eine geriatrische Vorsorgeuntersuchung im unausgelesenen Patientengut der Allgemeinpraxis.

To investigate the feasibility of early assessment of preventable disabilities in primary care, we developed a geriatric preventive screening examination with various indicators of physical, emotional, and social functions as well as laboratory exams. Cognitive impairment was measured by the modified MMSE. Severe cases of dementia, who would deserve home visits were excluded. Results of the assessment procedure in 446 patients aged 70 and over (71.5% females) were compared to ratings of general practitioners (n = 67). In these patients we found 4250 medical, 374 psychiatric, and 528 social problems. 45.4% of medical, 61.8% of psychiatric, and 56.8% of social problems where hitherto unknown to the GPs. The prevalence of cognitive impairment was 4.6% according to GPs diagnosis and 21% according to the MMSE. The sensitivity of GPs diagnosis was 14%, the specificity 98%, and the overall agreement measured by kappa was 0.17. There were significant (p < 0.05) associations of cognitive impairment with poor health, vascular disease, syncope, weight loss, previous hospitalization, depression, and ADL and IADL-items. Hypertension, or pathological thyroid function, occurred more frequently in the cognitively impaired (p > 0.05). Only 19.5% of dementia cases had severe functional loss, which substantiates our hypothesis that mild dementia was studied. Of all cases with newly identified cognitive impairment (n = 83 of 446 patients), three (3.6%) had reversible disorder such as depression (n = 1), drug toxicity (n = 2) 3 (3.6%) received counseling, and 5 (6%) further diagnostic assessment or treatment. One (1.2%) patient did not accept any treatment. In the remainder of 71 patients (85.5%), the GPs adopted a wait and see strategy with no intervention. In conclusion, memory deficits seem to be underdiagnosed in general practice despite much treatable comorbidity or social problems, and some reversible conditions such as depression and drug adverse effects.

Changes of laboratory markers of cognitive brain function by thermostimuli in the elderly.

OBJECTIVE: Plain external applications of physical stimuli, which are used quite commonly in geriatric care in Germany, have not been studied for their influence on cognitive brain function. The aim of this randomized crossover study was to examine the influence of dermatoreceptive stimuli on cognitive brain function in healthy geriatric volunteers. METHODS: Twenty-four healthy volunteers (23 women, 1 man) were randomized into two groups (crossover design). Group A (mean age, 68.8+/-6.2 [SD] years) was treated with a 10 degrees C to 12 degrees C cold stimulus for 10 seconds (a so-called "Kneipp face shower"), followed by a cold 10 degrees C to 12 degrees C wetpack at the neck for 1 minute. Group B (mean age, 69.8+/-5.3 [SD] years) was subjected to an identical procedure but with warm to neutral temperatures of 34 degrees C to 36 degrees C. After I week the two groups were interchanged. The parameters of interest were the critical flicker frequency (CFF) and the latencies of the event-related P-300 potentials of the visual evoked potentials (VEP), which can be considered an electroencephalographic marker of the cognitive functional ability. The CFFs and the P-300 latencies and amplitudes were measured directly both before and 10 minutes after the application of the respective stimuli. In addition, the CFFs were recorded 30 and 60 minutes later. RESULTS: After cold water stimuli were applied, the CFF increased from 32.55+/-2.26/sec (mean+/-SD) to 33.06+/-2.25/sec (p = .003) 10 minutes after the stimulus. Thirty minutes later the CFF was still elevated at 32.95+/-2.3/sec (p = .043). The P-300 latencies, after cold water application, decreased by 4.8% (p < .001), from 266.5+/-21.1msec (mean+/-SD) to 253.7+/-16.9msec. After warm stimuli they increased from 258.69+/-14.8msec to 266.17+/-20.1msec (p = .01). The P-300 amplitudes were significantly elevated, by 5% (p = .004), only after cold stimuli. CONCLUSION: Cold water applied locally to the face and neck region can provoke significant changes in electroencephalographic markers as measured by an electroencephalographic marker (VEP and P-300 latency) and, by inference, may help to improve cognitive function in the elderly.

Cerebral autoregulation during whole-body hypothermia and hyperthermia stimulus.

The purpose of the study contained herein was to investigate the effects of old traditional physiotherapeutic treatments on cerebral autoregulation. Treatment consisted of complete body immersion in cold or warm water baths. Fifteen volunteers were investigated by means of transcranial Doppler sonography and a servo-controlled noninvasive device for blood pressure measuring. One group of 8 volunteers (mean age, 27.2+/-3.5 yr; gender, 3 females/5 males) was subjected to cold baths of 22 degrees C for 20 min Another group of 7 volunteers (mean age, 52.1+/-8.5 yr; gender, 4 females/3 males) took hyperthermic baths at rising water temperatures from 36 degrees to 42 degrees C, increased by 1 degree C every 5 min. Each volunteer in both groups underwent autoregulation tests two to four times before, during, and after the thermic bath. Dynamic autoregulation was measured by the response of cerebral blood flow velocity to a transient decrease of the mean arterial blood pressure, induced by rapid deflation of thigh cuffs. The autoregulation index, i.e., a measure of the speed of change of cerebral autoregulation, was used to quantify the response. Further parameters were core temperature, blood pressure (mm Hg) and CO2et. During hypothermic baths, core temperature decreased by 0.3 degrees C (P = 0.001), measured between preliminary phase and the end of the bath; the autoregulation index decreased significantly (P < 0.05) from 5.3 before the bath to 4.25 during the bath. During hyperthermic baths, the autoregulation index increased from 6.0 to 7.5 and 8.9 (P < 0.001), with an increase of core temperature of 0.4 degrees C. The main cerebral autoregulation system is dependent on changes of core temperature, provoked by hypothermic or hyperthermic whole-body thermostimulus. Application of hyperthermic baths increased the autoregulation index, and hypothermic baths decreased the autoregulation index. Further studies are needed to prove the positive effects of thermo-stimulating water applications on cerebral hemodynamics in patients with cerebral diseases.

[Promoting quality and quality circles from the viewpoint of established physicians--representative Bremen and Saxony-Anhalt results]. / Qualitätsförderung und Qualitätszirkel aus der Sicht niedergelassener Arztinnen und Arzte--repräsentative Ergebnisse aus Bremen und Sachsen-Anhalt.

RESEARCH QUESTION: To study the attitudes of ambulatory care physicians towards quality improvement, the intentions to join quality circles (QCs, peer review groups) and the expectations directed towards them. METHODS/SETTING: Survey with a five-page questionnaire posted to all ambulatory care physicians in the German states of Saxony-Anhalt (n = 3139) and Bremen (n = 1131). RESULTS: Response rates were 61.8% in Saxony-Anhalt and 41.7% in Bremen. 2412 questionnaires were available in this largest survey on that topic in Germany. Necessity of quality improvement (QI) in ambulatory care was approved by the majority of the respondents (1.7 on a 5-point Lickert scale). Concerns existed about a rise in control and the risk of abuse of QI measures. 56.4% in Saxony-Anhalt and 52.3% in Bremen had the intention to join a QC. Motives and impediments of participation in QCs were investigated by content analysis. A causal dominance analysis was performed to identify the key elements for the decision to participate. The main benefits of QC-participation were expected as assistance in daily practice and exchange of experiences. The major obstacles were professional and private duties, fear of control and inefficiency. CONCLUSIONS: Policies that could be adequate to rise motivations and tackle on widespread fears should be purposely adapted to the needs and expectations of the physicians.

[Vision disorders in the elderly]. / Sehstörungen im Alter.

BACKGROUND: British trials from the 60's reveal that older patients tend to underreport their health problems. They misjudge them as non specific or being caused by old age. In this study we investigate whether standard preventive assessment facilitates the detection and early intervention of ophthalmological problems in old age. METHODOLOGY: For the first time a representative screening trial for older patients visiting their general practitioner was carried out in Germany, 1994. The surgeries as well as the 466 participating patients over 69 years were randomly selected. GPs were asked to examine the visual problems of the participants per standardized questionnaire and visual accuracy test. GPs had to report uncovered problems and planned interventions. RESULTS: Altogether, 75% of the participating patients had some need for a further ophthalmological diagnostic or therapeutic intervention. Every fourth patient had not seen an ophthalmologist within the last two years. 40% of the participants complained of eye problems. 22% had symptoms of a glaucoma. Visual accuracy was low in 17% of the older patients. General practitioners had only been aware of 50% of all visual problems requiring further intervention. About half of the patients with a low visual accuracy and 70% with an indication of glaucoma had been unknown before. For about half of the patients requiring ophthalmological investigation (excluding problems with glasses) an intervention was planned. For every fifth, the general practitioners initiated referrals. CONCLUSION: The standard preventive facilitated to detect a high rate of visual problems in old age. Close cooperation with ophthalmologists is necessary for patients who do not take up the specialists' eye check ups (especially those at risk). Patients with severe eye problems in some cases in spite of specialists' care also require interdisciplinary treatment.

Experiencia en torno al proceso de alta en pacientes crónicas del departamento 11 (mujeres) del servicio B, Hospital Psiquiátrico Dr. José Horwitz Barak / Experience in the discharge process in chronical patients of the Department 11 (women) of the Service B, Psychiatric Hospital Dr. José Horwitz Barak

Se describe la experiencia en torno al egreso de pacientes crónicos con largas estadías en el hospital. El alta se concreta tras un proceso que comprende múltiples actividades: elección de candidatas al egreso, psicoterapia de grupo dirigida a las mismas, evaluación de la tolerancia de la familiade origen o sustituta. Se detalla la estrategia de negociación del alta con los familiares. Se ilustra nuestra experiencia en dos casos clínicos. Finalmente comentamos respecto a algunas conclusiones de acuerdo a los resultados, y se exponen ideas en relación al proceso de alta y concepto de rehabilitación

[A new concept of psychosomatic research exemplified by premature labor]. / Ein neues Konzept psychosomatischer Forschung am Beispiel der vorzeitigen Wehentätigkeit.

One of the most serious problems of psychosomatic research is the adequate choice of the method applied to clinical questions. In the past empirical investigations have been based upon univariate and moreover linear correlations. In this study a multivariate nonlinear concept was developed which was generated in a first trial proven and confirmed prospectively in a second one using two sorts of mathematical analyses. The first included 35 patients with premature labour and 25 healthy pregnant women as controls. The latter was conducted with 238 patients being recruited in the first trimester of pregnancy, 30 of whom developed premature labour in the course of the study. Using a questionnaire consisting of the main aetiological variables identified in the basic investigation and using the statistical procedures mentioned above the occurrence of premature labour was predicted in more than 90%. Only one patient who was not suspected to develop premature uterine activity was not classified correctly. Besides clinical usefulness the model of research presented provides evidence for the most important aetiologic conditions of the disease as far as psychosocial factors are concerned and offers a new approach to quantifying research including somatic and non-somatic variables.

Peak centred power spectra: a successful attempt to calculate efficient parameters in the alpha range of EEG.

This paper presents a parametrization method for the alpha range of EEG Fourier spectra which obviates the limitations of conventional frequency partition and is concerned with the location of the individual peak frequency. The superiority of this procedure in comparison with the conventional method could be shown through the performance of a cross validation.