A multifactorial interdisciplinary intervention to prevent functional and mobility decline for more participation in (pre-)frail community-dwelling older adults (PromeTheus): study protocol for a multicenter randomized controlled trial.

BACKGROUND: Age-related decline in physical capacity can lead to frailty, associated with an increased vulnerability to adverse health outcomes and greater healthcare utilization. In an aging population, effective strategies to prevent physical decline and frailty, and preserve independence are needed. Prevention programs for vulnerable community-dwelling older adults are, however, often not yet established and implemented in routine practice. Research on the feasibility, implementation, and (cost-)effectiveness of multifactorial, interdisciplinary intervention programs that take advantage of available services of healthcare providers is also limited. The main aim of this study is to evaluate the effectiveness of such an intervention program (PromeTheus) to prevent functional and mobility decline for more participation in community-dwelling (pre-)frail older adults. METHODS: The study is designed as a three-center, randomized controlled trial with a 12-month intervention period. Four hundred community-dwelling (pre-)frail (Clinical Frailty Scale score 4-6) older adults (≥70 years) will be randomized in a 1:1 ratio to the intervention group (IG) or the control group (CG). The IG will receive the PromeTheus program consisting of obligatory home-based physical exercises (Weight-bearing Exercise for Better Balance) accompanied by physiotherapists and facultative counseling services (person-environment-fit, coping with everyday life, nutrition, group-based activities) delivered via existing healthcare structures (e.g., social workers, nutritionists). The CG will receive usual care and a one-time counseling session on recommendations for physical activity and nutrition. Primary outcomes assessed at months 6 and 12 are the function component of the Late-Life Function and Disability Instrument and the University of Alabama at Birmingham Life-Space Assessment. Secondary outcomes are disability, physical capacity and activity, frailty, nutritional status, falls, fear of falling, health status, and psychosocial components. Process and economic evaluations are also conducted. Primary statistical analyses will be based on the intention-to-treat principle. DISCUSSION: Compared to usual care, the PromeTheus program is expected to result in higher function and mobility, greater independence and lower need for care, and more participation. As the PromeTheus program draws on existing German healthcare structures, its large-scale translation and delivery will be feasible, if evidence of (cost-)effectiveness and successful implementation can be demonstrated. TRIAL REGISTRATION: German Clinical Trials Register, . Registered on March 11, 2021.

Care challenges in older general hospital patients : Impact of cognitive impairment and other patient-related factors.

BACKGROUND: Older general hospital patients, particularly those with cognitive impairment, frequently experience adverse events and other care complications during their stay. As these findings have so far been based on small and selected patient samples, the aim of the present study was to provide reliable data on a) the prevalence of adverse care issues (summarized under the term care challenges) in older general hospital patients and on b) associated patient-related risk factors (e.g. cognitive impairment). METHODS: A cross-sectional representative study comprising 1469 patients aged ≥65 years from 33 randomly selected general hospitals in southern Germany (GHoSt). Data collection included the use of different data sources, e.g. structured interviews with responsible nursing staff concerning care challenges and procedures for determining the patients' cognitive status. RESULTS: Care challenges were statistically significantly (p < 0.001) more often reported for patients with dementia and/or delirium (87.5%) and mild cognitive impairment (47.9%) compared to cognitively unimpaired patients (24.6%). Adjusted odds ratios suggested cognitive impairment, impaired activities of daily living, receiving long-term care and unplanned admission as significant patient-related risk factors for care challenges. Furthermore, the occurrence of such issues was associated with the application of physical restraints, support from relatives, prescription of psycholeptics and specialist consultations. CONCLUSION: The findings suggest a strong impact of different degrees of cognitive impairment on challenges in care. The results might help to design appropriate training programs for hospital staff and other interventions to prevent or reduce critical situations.

Multifactorial intervention for hip and pelvic fracture patients with mild to moderate cognitive impairment: study protocol of a dual-centre randomised controlled trial (OF-CARE).

BACKGROUND: A hip or pelvic fracture is a major fall-related injury which often causes a decline in mobility performance and physical activity. Over 40% of patients with hip fracture have cognitive impairment or dementia and poorer rehabilitation outcomes than those without cognitive impairment. In this subgroup, there is a lack of evidence on the best practices supporting recovery. The main aim of this study is to investigate the effects of a transitional care intervention after inpatient rehabilitation on physical activity and functional performance in this group of cognitively impaired patients. METHODS/DESIGN: This dual-centre, randomised controlled trial compares a multifactorial intervention with usual care as control condition. Two hundred and forty community-dwellers (≥ 65 years) with a hip or pelvic fracture and mild to moderate cognitive impairment (MMSE 17-26) are recruited at the end of inpatient rehabilitation. The four-month intervention consists of (a) an individually tailored, progressive home exercise program and physical activity promotion delivered by professional instructors and lay instructors (two home visits per week) and (b) a long-term care counselling approach addressing unmet care needs, pleasurable activities, and caregiver issues if needed. Primary outcome parameters are physical activity, measured as daily walking duration with an accelerometer-based activity monitor (activPAL™) over 72 h, and functional performance, assessed with Short Physical Performance Battery sum scores. Secondary outcome parameters are fear of falling, fall related self-efficacy, falls, quality of life, depression and activity of daily living. Data are collected at the end of rehabilitation, before the intervention at the patient's home (baseline), after four months (post-intervention), and seven months (follow-up). In addition to completer and intent-to-treat analyses of outcomes, economic data and incremental cost-effectiveness are analysed. DISCUSSION: Existing service models of volunteer services and legal counselling provided by care counsellors were considered when developing the intervention protocol. Therefore, it should be feasible to translate and deliver the intervention into real-world practice if it has been demonstrated to be effective. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00008863 (Accessed 17 Apr 2019), ISRCTN registry, ISRCTN69957256 (Accessed 17 Apr 2019).

The Prevalence of Dementia and Cognitive Impairment in Hospitals.

BACKGROUND: The care of elderly patients with comorbid dementia poses an increasing challenge in the acute inpatient setting, yet there remains a lack of representative studies on the prevalence and distribution of dementia in general hospitals. METHODS: We conducted a cross-sectional study of patients aged 65 and older in randomly selected general hospitals in southern Germany. Patients were excluded if they were in an intensive care unit or isolation unit or if they were on specialized wards for psychiatry, neurology, or geriatric medicine. The findings are derived from patient interviews, neuropsychological testing, standardized rating scales, questioning of nursing staff, and the patients' medical records. RESULTS: 1469 patients on 172 inpatient wards of 33 hospitals were studied. 40.0% of them (95% confidence interval, [36.2; 43.7]) had at least mild cognitive impairment. The point-prevalence of dementing illnesses was 18.4% [16.3; 20.7]. Delirium, most often on the basis of dementia, was present in 5.1% [3.9; 6.7]. 60.0% had no cognitive impairment. Dementia was more common among patients of very advanced age, those who were dependent on nursing care, those who lived in old-age or nursing homes, and those with a low level of education. Among patients with dementia, only 36.7% had a documented diagnosis of dementia in the medical record. Patients with dementia were treated more often for dehydration, electrolyte disturbances, urinary tract infections, contusions, and bone fractures, as well as for symptoms and findings of an unknown nature, and much less often for cancer or musculoskeletal diseases. CONCLUSION: Two out of five elderly patients in general hospitals suffer from a cognitive disturbance. Patients with severe impairments such as dementia or delirium often need special care. Guidelines and model projects offer approaches by which the inpatient care of patients with comorbid dementia can be improved.

[Factors which influence the position towards euthanasia : Results of a representative survey among older people in Germany]. / Einflussfaktoren auf die Positionierung gegenüber Sterbehilfe : Ergebnisse einer repräsentativen Studie in der Altenbevölkerung.

BACKGROUND: Until now older adults have not been a target group for surveys regarding their personal attitudes towards euthanasia, although they are closest to chronic illness and death. OBJECTIVE: To determine the attitudes of older adults towards euthanasia and controversial topics in the context of illness, euthanasia and care (e. g. palliative care) on the basis of a representative sample. MATERIAL AND METHODS: The study was based on a postal survey of a representative random sample of the population aged 65 years and older (n = 3500) from a city in southern Germany using a standardized questionnaire. RESULTS: A total of 1068 persons completed the questionnaire (response rate 30.5%). Assisted death was supported by 74.2% of the respondants and assisted suicide by 80.4%. According to multiple logistic regression analysis the support decreased with increasing strength of religious faith and a non-German country of origin. Of the participants 53.3% were worried about being a burden to their family, especially people with a limited state of health. People who shared this concern showed significantly more support for both types of euthanasia. More than 40% feared that people with severe and incurable illnesses would be more likely to be forced into a premature death (slippery slope argument). This concern was associated with a decreasing support of euthanasia. CONCLUSION: The results indicate that the strong approval of the legalization of assisted death and assisted suicide by older people is motivated not only by their desire for a self-determined death but also by fears and concerns. The findings have important implications for counseling, palliative care and treatment.

[Dementia friendly care services in general hospitals : Representative results of the general hospital study (GHoSt)]. / Demenzsensible Versorgungsangebote im Allgemeinkrankenhaus : Repräsentative Ergebnisse aus der General Hospital Study (GHoSt).

BACKGROUND: Mostly model projects report on special care services and procedures for general hospital patients with cognitive impairment. The objective of this study was to determine the frequency of special care services and procedures in general hospitals on the basis of a representative cross-sectional study. METHODS: From a list of all general hospitals in southern Germany we randomly selected a specified number of hospitals und somatic wards. The hospitals were visited and all older patients on the selected wards on that day were included in the study. Information about care services and their utilization was collected with standardized instruments. RESULTS: A total of 33 general hospitals and 172 wards participated in the study. The patient sample included 1469 persons over 65 (mean age 78.6 years) and 40% of the patients showed cognitive impairments. The staff reported that the most frequent measures for patients with cognitive impairments concerned patients with wandering behavior (63.1%), efforts to involve the patients' relatives to help with their daily care (60.1%), conducting nonintrusive interviews to identify cognitive impairments (59.9%), allocation to other rooms (58%) and visual aids for place orientation of patients (50.6%). In accordance with earlier studies our results show that other dementia friendly services implemented in pilot projects were rare. The existing special services for patients with cognitive impairment were rarely used by the patients or their relatives. DISCUSSION: The results demonstrate the urgent need to improve special care services and routines for identification of elderly patients with cognitive impairment and risk of delirium in general hospitals.

The 6-Item Cognitive Impairment Test as a bedside screening for dementia in general hospital patients: results of the General Hospital Study (GHoSt).

OBJECTIVE: The objective of this study was to examine the psychometric quality of the 6-Item Cognitive Impairment Test (6CIT) as a bedside screening for the detection of dementia in general hospital patients. METHOD: Participants (N = 1,440) were inpatients aged ≥65 of 33 randomly selected general hospitals in Southern Germany. The 6CIT was conducted at bedside, and dementia was diagnosed according to DSM-IV. Nursing staff was asked to rate the patients' cognitive status, and previous diagnoses of dementia were extracted from medical records. Completion rates and validity statistics were calculated. RESULTS: Two-hundred seventy patients had dementia. Cases with delirium but no dementia were excluded. Feasibility was 97.9% and 83.3% for patients without and with dementia, respectively, and decreased from moderate (93.8%) to severe dementia (53%). The area under the curve of the 6CIT was 0.98. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for the cutoffs 7/8 (0.96, 0.82, 0.85, 0.52, 0.99) and 10/11 (0.88, 0.95, 0.94, 0.76, 0.98). The nurse ratings and medical records information had lower validity statistics. Logistic regression analyses revealed that the 6CIT statistically significantly provided information above nurse ratings and medical records. Twenty-five and 37 additional patients were correctly classified by the 7/8 and 10/11 cutoffs, respectively. CONCLUSION: The 6CIT is a feasible and valid screening tool for the detection of dementia in older general hospital patients. The 6CIT outperformed the nurse ratings of cognitive status and dementia diagnoses from medical records, suggesting that standardized screening may have benefits with regard to case finding. Copyright © 2016 John Wiley & Sons, Ltd.

[Prevalence of dementia and medical care in German nursing homes: a nationally representative survey]. / Prävalenz von Demenzen und ärztliche Versorgung in deutschen Pflegeheimen: eine bundesweite repräsentative Studie.

OBJECTIVE: The study aimed to determine the prevalence of dementia and the degree of medical care among residents of nursing homes based on a nationally representative sample of nursing homes in Germany for the first time. METHODS: Based on a probability sample of 609 long-term care institutions in Germany, we drew a sample of 86 facilities by applying a two-stage random procedure. All residents of the participating care facilities were comprehensively assessed by qualified nurses using a standardized Care and Behavior Assessment (CBA). RESULTS: Of the 4,481 residents assessed in 58 care facilities (mean age 82.6 years;78 % female) on average 68.6 % (95 % CI: 67.0 - 69.8) were affected by a dementia-syndrome, 56.6 % by a severe dementia-syndrome. There were frequent contacts between residents and general practitioners, but provision of specialized medical care seemed to be deficient in many aspects. CONCLUSION: People with dementia form the major group of residents in German nursing homes. The study provides important data on need for care and health care planning.

Evaluation of special and traditional dementia care in nursing homes: results from a cross-sectional study in Germany.

OBJECTIVE: Two-thirds of all residents in nursing homes in Germany suffer from some type of dementia. We investigated whether or not dementia patients receiving special (segregated or partially segregated) care exhibited a better quality of life than their counterparts residing in traditional nursing homes. METHODS: In a cross-sectional study in 28 special dementia care facilities in the city of Hamburg (admission criterion: mobile dementia patients with behaviour problems) 594 residents were compared to a group of nursing home residents with dementia (n = 573) in 11 randomly selected nursing homes who were receiving traditional integrative care. Primary features such as cognitive and functional impairment, and behaviour problems were assessed by qualified nursing staff. RESULTS: Controlling for confounding variables, for dementia patients in special care units as compared to a reference group in traditional integrative care, the level of volunteer caregiver involvement was higher and there was more social contact to staff, fewer physical restraints, more involvement in home activities, and more frequent use of psychiatrists. There was no significant difference between the two care settings with regard to overall use of psychotropic drugs, however, residents in special dementia care used antipsychotics significantly less often and antidepressants more often. CONCLUSIONS: Significant differences for a number of indicators of the quality of life point in favour of special dementia care. Future evaluation studies ought to examine not only the general efficacy of types of care designed especially for dementia patients but also the efficacy of the respective individual components (i.e. caregiver ratio).