Transferability and Sustainability of Motor-Cognitive Dual-Task Training in Patients with Dementia: A Randomized Controlled Trial.

BACKGROUND: Specific dual-task (DT) training is effective to improve DT performance in trained tasks in patients with dementia (PwD). However, it remains an open research question whether successfully trained DTs show a transfer effect to untrained DT performances. OBJECTIVE: To examine transfer effects and the sustainability of a specific DT training in PwD. METHODS: One hundred and five patients with mild-to-moderate dementia (Mini-Mental State Examination: 21.9 ± 2.8 points) participated in a 10-week randomized, controlled trial. The intervention group (IG) underwent a specific DT training ("walking and counting"). The control group (CG) performed unspecific low-intensity exercise. DT performance was measured under three conditions: (1) "walking and counting" (trained); (2) "walking and verbal fluency" (semi-trained), and (3) "strength and verbal fluency" (untrained). Outcomes evaluated at baseline, after training, and 3 months after the intervention period included absolute values for the motor and cognitive performance under DT conditions, and relative DT costs (DTCs) in motor, cognitive and combined motor-cognitive performance. RESULTS: The IG significantly improved DT performances in the trained condition for absolute motor and cognitive performance and for motor, cognitive, and combined motor-cognitive DTCs compared to the CG (p ≤ 0.001-0.047; ηp2 = 0.044-0.249). Significant transfer effects were found in the semi-trained condition for absolute motor and partly cognitive performance, and for motor but not for cognitive DTCs, and only partly for combined DTCs (p ≤ 0.001-0.041; ηp2 = 0.049-0.150). No significant transfer effects were found in the untrained condition. Three months after training cessation, DT performance in the trained condition was still elevated for most of the outcomes (p ≤ 0.001-0.038; ηp2 = 0.058-0.187). Training gains in the DT performance in the semi-trained condition were, however, not sustained, and no significant group differences were found in the DT performance in the untrained condition after the follow-up. CONCLUSION: This study confirmed that specific DT training is effective in improving specifically trained DT performances in PwD and demonstrated sustainability of training-induced effects for at least 3 months. Effects were partially transferable to semi-trained DTs but not to untrained DTs. With increasing distance between trained and untrained DTs, transferability of training effects decreased.

Falls and Physical Activity in Persons With Mild to Moderate Dementia Participating in an Intensive Motor Training: Randomized Controlled Trial.

BACKGROUND: Physical activity is beneficial in people with dementia. As physical activity increases risk exposure for falls, safety concerns arise. Prior exercise trials in people with dementia have not measured physical activity. Falls in relation to exposure time rather than person-years as outcome measure has been promoted but not investigated in people with dementia. METHODS: Patients with mild to moderate dementia (n=110) were randomized to an intensive, progressive strength and functional training intervention or to a low-intensity group training for 12 weeks each. Physical activity was measured with a standardized questionnaire. Falls were documented prospectively by calendars for 12 months. RESULTS: During the intervention, physical activity was significantly higher in the intervention group (P<0.001) without an increased fall rate (intervention group vs. CONTROL GROUP: 2.89 vs. 1.94; incidence rate ratio, 1.49; 95% confidence interval, 0.66-3.36; P=0.333). In the subgroup of multiple fallers, the number of falls per 1000 hours of activity was significantly lower in the intervention group (8.85 vs. 18.67; P=0.017). CONCLUSIONS: Increased physical activity during exercise intervention was safe in people with mild to moderate dementia. Fall rate adjusted for physical activity is a useful and sensitive outcome measure in addition to fall rate per person-years.

Living with and dying from advanced heart failure: understanding the needs of older patients at the end of life.

BACKGROUND: Heart failure (HF) is a life-limiting illness and patients with advanced heart failure often suffer from severe physical and psychosocial symptoms. Particularly in older patients, HF often occurs in conjunction with other chronic diseases, resulting in complex co-morbidity. This study aims to understand how old and very old patients with advanced HF perceive their disease and to identify their medical, psychosocial and information needs, focusing on the last phase of life. METHODS: Qualitative longitudinal interview study with old and very old patients (≥70 years) with severe HF (NYHA III-IV). Interviews were conducted at three-month intervals over a period of up to 18 months and were analysed using qualitative methods in relation to Grounded Theory. RESULTS: A total of 95 qualitative interviews with 25 patients were conducted and analysed. The following key categories were developed: (1a) dealing with advanced heart failure and ageing, (1b) dealing with end of life; (2a) perceptions regarding care, and (2b) interpersonal relations. Overall, our data show that older patients do not experience HF as a life-limiting disease. Functional restrictions and changed conditions leading to problems in daily life activities were often their prime concerns. The needs and priorities of older HF patients vary depending on their disease status and individual preferences. Pain resulting in reduced quality of life is an example of a major symptom requiring treatment. Many older HF patients lack sufficient knowledge about their condition and its prognosis, particularly concerning emergency situations and end of life issues, and many expressed a wish for open discussions. From the patients' perspective, there is a need for improvement in interaction with health care professionals, and limits in treatment and medical care are not openly discussed. CONCLUSION: Old and very old patients with advanced HF often do not acknowledge the seriousness and severity of the disease. Their communication with physicians predominantly focuses on curative treatment. Therefore, aspects such as self-management of the disease, dealing with emergency situations and end-of-life issues should be addressed more prominently. An advanced care planning (ACP) programme for heart disease in older people could be an option to improve patient-centred care.

Swallowing Tablets and Capsules Increases the Risk of Penetration and Aspiration in Patients with Stroke-Induced Dysphagia.

We evaluated the prevalence of difficulties swallowing solid dosage forms in patients with stroke-induced dysphagia and whether swallowing tablets/capsules increases their risk of penetration and aspiration. Concurrently, we explored whether routinely performed assessment tests help identify patients at risk. Using video endoscopy, we evaluated how 52 patients swallowed four different placebos (round, oval, and oblong tablets and a capsule) with texture-modified water (TMW, pudding consistency) and milk and rated their swallowing performance according to the Penetration Aspiration Scale (PAS). Additionally, Daniels Test, Bogenhausener Dysphagiescore, Scandinavian Stroke Scale, Barthel Index, and Tinetti's Mobility Test were conducted. A substantial proportion of the patients experienced severe difficulties swallowing solid oral dosage forms (TMW: 40.4 %, milk: 43.5 %). Compared to the administration of TMW/milk alone, the placebos increased the PAS values in the majority of the patients (TMW: median PAS from 1.5 to 2.0; milk: median PAS from 1.5 to 2.5, each p value <0.0001) and residue values were significantly higher (p < 0.05). Whereas video-endoscopic examination reliably identified patients with difficulties swallowing medication, neither patients' self-evaluation nor one of the routinely performed bedside tests did. Therefore, before video-endoscopic evaluation, many drugs were modified unnecessarily and 20.8 % of these were crushed inadequately, although switching to another dosage form or drug would have been possible. Hence, safety and effectiveness of swallowing tablets and capsules should be evaluated routinely in video-endoscopic examinations, tablets/capsules should rather be provided with TMW than with milk, and the appropriateness of "non per os except medication" orders for dysphagic stroke patients should be questioned.

Definitions and methods of measuring and reporting on injurious falls in randomised controlled fall prevention trials: a systematic review.

BACKGROUND: The standardisation of the assessment methodology and case definition represents a major precondition for the comparison of study results and the conduction of meta-analyses. International guidelines provide recommendations for the standardisation of falls methodology; however, injurious falls have not been targeted. The aim of the present article was to review systematically the range of case definitions and methods used to measure and report on injurious falls in randomised controlled trials (RCTs) on fall prevention. METHODS: An electronic literature search of selected comprehensive databases was performed to identify injurious falls definitions in published trials. Inclusion criteria were: RCTs on falls prevention published in English, study population ≥ 65 years, definition of injurious falls as a study endpoint by using the terms "injuries" and "falls". RESULTS: The search yielded 2089 articles, 2048 were excluded according to defined inclusion criteria. Forty-one articles were included. The systematic analysis of the methodology applied in RCTs disclosed substantial variations in the definition and methods used to measure and document injurious falls. The limited standardisation hampered comparability of study results. Our results also highlight that studies which used a similar, standardised definition of injurious falls showed comparable outcomes. CONCLUSIONS: No standard for defining, measuring, and documenting injurious falls could be identified among published RCTs. A standardised injurious falls definition enhances the comparability of study results as demonstrated by a subgroup of RCTs used a similar definition. Recommendations for standardising the methodology are given in the present review.

Feasibility and accuracy of fall reports in persons with dementia: a prospective observational study.

BACKGROUND: The feasibility, test-retest reliability, and accuracy of different fall recording methods have not been studied in older persons with dementia. METHODS: This was a prospective observational study, nested within a randomized controlled trial on motor training, in which 110 participants were monitored for falls over 12 months. Seven methods of fall recording were compared: face-to-face interviews; phone interviews: weekly for three months, monthly for 9 months, a final interview after 12 months; prospective calendar method; interviews with a proxy and the general practitioner (GP). Summing the count of falls and removing duplicate reporting of the same fall was found to provide the best approximation of the actual number of falls and was chosen as the criterion-standard. RESULTS: The combination of calendar method and phone interviews showed the highest accuracy (74% of falls, 93% of fallers). As a single measure, weekly phone calls were superior to calendars or proxy-report. Monthly phone calls recorded only half the falls that were picked up by weekly calls (p = 0.002) and were inferior to the calendars (p<0.001) and proxy-report (p = 0.015). GPs knew of only 14% of falls and 19% of fallers. In addition, 49% of subjects who documented a fall prospectively did not recall a fall after 12 months. CONCLUSION: The combination of fall calendars with regular telephone interviews can be recommended for persons with mild to moderate stage dementia. If feasible, recall periods should be as short as one week; additional information by care-givers increases accuracy of reports. Retrospective recall of falling with long recall periods is not recommended.

Validity and sensitivity to change of the falls efficacy scales international to assess fear of falling in older adults with and without cognitive impairment.

BACKGROUND: Measures of fear of falling have not yet been validated in patients with dementia, leaving a methodological gap that limits research in a population at high risk of falling and fall-related consequences. OBJECTIVE: The objectives of this study are to determine: (1) the validity of the 7-item Short Falls Efficacy Scale International (Short FES-I) in geriatric patients with and without cognitive impairment, and (2) the sensitivity to change of the 10-item Falls Efficacy Scale (FES), the 16-item FES-I and the 7-item Short FES-I in geriatric patients with dementia. METHODS: Cross-sectional data of community-dwelling older adults and geriatric rehabilitation patients (n = 284) collected during face-to-face interviews were used to determine construct and discriminant validity by testing for differences within variables related to fear of falling. Sensitivity to change was studied in an intervention study including patients with mild to moderate dementia (n = 130) as determined by standard response means (SRMs). RESULTS: The Short FES-I showed excellent construct and discriminant validity in the total group and subsamples according to cognitive status. Sensitivity to change was adequate to good in the FES (range SRM: 0.18-0.77) and FES-I (range SRM: 0.21-0.74), with the Short FES-I showing the highest peak sensitivity to change (range SRM: 0.18-0.91). CONCLUSIONS: The Short FES-I is a valid measure to assess fear of falling in frail older adults with and without cognitive impairment, yet it may show floor effects in higher functioning older people. All scales, including the Short FES-I, were sensitive to detecting intervention-induced changes in concerns about falling in geriatric patients with dementia.

Stimulation of acupoint ST-34 acutely improves gait performance in geriatric patients during rehabilitation: A randomized controlled trial.

OBJECTIVE: To determine whether a specific regimen of acupoint stimulation improved gait performance in geriatric patients. DESIGN: Multiple-blinded, randomized, controlled intervention trial. SETTING: Geriatric ward rehabilitation. PARTICIPANTS: 60 geriatric patients during rehabilitation. INTERVENTIONS: Both groups received a 1-time acupoint stimulation according to randomization. Stimulation of a verum acupoint (verum treatment) according to principles of traditional Chinese medicine was compared with a technically identical needle application on a nonacupoint (control treatment) in the control group. MAIN OUTCOME MEASURES: Descriptive parameters were documented by valid, established tests. Gait performance was objectively measured by an electronic walkway before needling and after needling. RESULTS: All gait parameters showed statistically significant improvement after verum treatment compared with control treatment (velocity, cadence, stride length, cycle time, step time, single support, double support: P values all <.05) except for the base of support (P=.163). Effect sizes achieved by 1-time stimulation of an acupoint were low and ranged from .08 to .24. No severe adverse clinical events related to the intervention occurred. CONCLUSIONS: Study results showed that a 1-time administration of a specific acupoint stimulation regimen statistically significantly improved gait performance during geriatric ward rehabilitation. If sustainability of effects can be documented, acupuncture may prove to be an inexpensive intervention that may mildly improve motor performance in frail geriatric patients.

Improving care for patients with dementia hospitalized for acute somatic illness in a specialized care unit: a feasibility study.

BACKGROUND: Persons with dementia hospitalized for an acute illness have a high risk of poor outcomes and add to the burden on acute care systems. We developed a segregated Special Care Unit (SCU) in a somatic hospital for patients with challenging behavior resulting from dementia and/or delirium. This pilot study evaluates the feasibility and patient outcomes. METHODS: The SCU was established with environmental features that allow for safe and unrestricted ambulation within the unit and create a home-like atmosphere. Daytime activities structure the day and assure additional professional presence. The staff received intensive specialized training. Feasibility criteria were: acceptance by the staff, avoidance of transfers to geriatric psychiatry, lack of serious falls and mortality. Patient outcome criteria were ADL (Barthel index), mobility scores and behavior scores (Wilcoxon's, McNemar tests, pre-post design). RESULTS: 332 consecutively admitted patients were enrolled. The SCU has been well received by the staff. Length of hospital stay did not differ from other hospital patients (15.3 +/- 8.3 vs. 15.0 +/- 10.3 days, p = 0.54). Six patients were transferred to geriatric psychiatry. Two patients suffered a fall-related hip fracture. The median Barthel Index improved significantly (admission 30, discharge 45, p < 0.001), with only 8.5% of patients suffering functional loss. Wandering, aggression and agitation were significantly reduced (p < 0.001). CONCLUSIONS: The SCU has improved the care of patients with challenging behavior. Decline in ADL function and institutionalization occurred to a lesser degree than would be expected in this group of patients. Despite the selection of patients with behavioral problems, transfer to psychiatry was rare.

[Outpatient care for the old and very old]. / Ambulante Versorgung älterer und hochaltriger Patienten.

BACKGROUND: Outpatient treatment of elderly patients is the responsibility of the family doctor. In addition to general practitioner care, there are some regionally different models that are currently not established and evaluated in Germany. The investigation presented here aims to contribute to the profiling of outpatient geriatric care in the future. METHOD: A full survey on the attitude and acceptance of general practitioners towards outpatient geriatrics and a geriatric focus practice was carried out. At the same time, referral and advisory events were systematically recorded and compared. RESULTS AND CONCLUSION: A geriatric focus practice can complement primary care. It is well accepted by many family doctors if there is a transparent exchange, pilot function and basic family doctor activities remain with the family doctor and he is relieved of the burden on complex patients.

Validation of a German version of the Confusion Assessment Method for delirium detection in a sample of acute geriatric patients with a high prevalence of dementia.

OBJECTIVES: To assess validity and interrater reliability of an operationalized German version of the Confusion Assessment Method (CAM) in geriatric patients with comorbid dementia and high delirium risk. DESIGN: Prospective cross-sectional cohort study with double CAM assessment by a medical and nonmedical rater. SETTING: Random sample of frail, cognitively impaired elderly with acute disease requiring hospital care. PARTICIPANTS: A total of 39 frail elderly, mean age 83 +/- 7 years, 72% (n = 28) female, with cognitive impairments, a high prevalence of dementia (86%, n = 33) and a significant risk of delirium. Of these, 13 revealed delirium, which was superimposed on dementia in 11. MEASUREMENTS: A translated and operationalized version of the CAM was validated against a neuropsychiatric and geriatric consensus reference standard based on DSM-IV. Additional measures included the Short Portable Mental Status Questionnaire, the Mini-Mental State Examination and the Delirium Index for cognitive impairment severity, the Informant Questionnaire on Cognitive Decline for dementia diagnosis and the Barthel Index, illness severity (Cumulative Illness Rating Scale) and medication. RESULTS: Delirium was correctly detected by CAM algorithm in 10 out of 13 delirious patients resulting in a high sensitivity of 0.77 and a specificity of 0.96-1.00 for both raters. Likelihood ratio revealed an almost 20-fold risk of delirium with positive CAM testing. Interrater reliability was excellent with a Cohen's k of 0.95 (CI 0.74-1.0) for the algorithm, single items' k values varied between 0.5 and 1. CONCLUSIONS: The German CAM is a reliable and valid measure of delirium, even in frail, acutely diseased elderly with concomitant dementia.

Serum anticholinergic activity and cerebral cholinergic dysfunction: an EEG study in frail elderly with and without delirium.

BACKGROUND: Delirium increases morbidity, mortality and healthcare costs especially in the elderly. Serum anticholinergic activity (SAA) is a suggested biomarker for anticholinergic burden and delirium risk, but the association with cerebral cholinergic function remains unclear. To clarify this relationship, we prospectively assessed the correlation of SAA with quantitative electroencephalography (qEEG) power, delirium occurrence, functional and cognitive measures in a cross-sectional sample of acutely hospitalized elderly (> 80 y) with high dementia and delirium prevalence. METHODS: 61 consecutively admitted patients over 80 years underwent an extensive clinical and neuropsychological evaluation. SAA was determined by using radio receptor assay as developed by Tune, and standard as well as quantitative EEGs were obtained. RESULTS: 15 patients had dementia with additional delirium (DD) according to expert consensus using DSM-IV criteria, 31 suffered from dementia without delirium (D), 15 were cognitively unimpaired (CU). SAA was clearly detectable in all patients but one (mean 10.9 +/- 7.1 pmol/ml), but was not associated with expert-panel approved delirium diagnosis or cognitive functions. Delirium-associated EEG abnormalities included occipital slowing, peak power and alpha decrease, delta and theta power increase and slow wave ratio increase during active delirious states. EEG measures correlated significantly with cognitive performance and delirium severity, but not with SAA levels. CONCLUSION: In elderly with acute disease, EEG parameters reliable indicate delirium, but SAA does not seem to reflect cerebral cholinergic function as measured by EEG and is not related to delirium diagnosis.

Effects of metabolic control, patient education and initiation of insulin therapy on the quality of life of patients with type 2 diabetes mellitus.

OBJECTIVE: The objective of this study was to evaluate the impact of initiation of insulin therapy, metabolic control and structured patient education on the diabetes-related quality of life (QoL) in insulin-treated patients with type 2 diabetes mellitus. METHODS: This prospective study was conducted with 71 consecutively recruited patients with insulin-treated diabetes at the University hospital. All patients participated an inpatient diabetes treatment and teaching program (DTTP) for conventional insulin therapy (mean age 68.9 years, HbA1c 10.1+/-1.4%, diabetes duration 11.2 years (range: 0-25.5 years), body-mass-index 28.7+/-5.7 kg/m(2). Diabetes-related quality of life was assessed before and 6 months after participation in the DTTP using the standardized questionnaire of Lohr analysing the subscales: social relations, physical complaints, worries about the future, dietary restrictions, fear of hypoglycaemia, and daily struggles. RESULTS: Only patients switched on insulin therapy showed significant improvement in diabetes-related quality of life 6 months after participation in the DTTP (p=0.03), fewer physical complaints (p=0.03), fewer worries about the future (p=0.02), fewer daily struggles (p=0.01) and less fear of hypoglycaemia (p<0.001), while patients, who were already on insulin therapy showed no improvements in diabetes-related quality of life. Though, residual analysis reveals that effects on patients' QoL are mainly caused by improvements in metabolic control. CONCLUSIONS: Improvements in metabolic control have a significant effect on different diabetes-related quality of life domains in patients with diabetes mellitus. PRACTICE IMPLICATIONS: Appropriate interventions resulting in better metabolic control, such as starting on insulin therapy within a structured patient education program seem to be an effective approach to improve patients' diabetes-related quality of life.

People with Dementia Can Learn Compensatory Movement Maneuvers for the Sit-to-Stand Task: A Randomized Controlled Trial.

BACKGROUND: A complex motor skill highly relevant to mobility in everyday life (e.g., sit-to-stand [STS] transfer) has not yet been addressed in studies on motor learning in people with dementia (PwD). OBJECTIVE: To determine whether a dementia-specific motor learning exercise program enables PwD to learn compensatory STS maneuvers commonly taught in geriatric rehabilitation therapy to enhance patients' STS ability. METHODS: Ninety-seven patients with mild-to-moderate dementia (Mini-Mental State Examination: 21.9±2.9 points) participated in a double-blinded, randomized, placebo-controlled trial with 10-week intervention and 3-month follow-up period. The intervention group (IG, n = 51) underwent a motor learning exercise program on compensatory STS maneuvers specifically designed for PwD. The control group (CG, n = 46) performed a low-intensity motor placebo activity. Primary outcomes were scores of the Assessment of Compensatory Sit-to-stand Maneuvers in People with Dementia (ACSID), which covers the number of recalled and initiated, and of effectively performed compensatory STS maneuvers. Secondary outcomes included temporal and kinematic STS characteristics measured by a body-fixed motion sensor (BFS, DynaPort® Hybrid). RESULTS: The IG significantly improved in all ACSID scores compared to the CG (p < 0.001). Secondary analysis confirmed learning effects for all BFS-based outcomes (p < 0.001-0.006). Learning gains were sustained during follow-up for most outcomes. CONCLUSION: People with mild-to-moderate dementia can learn and retain compensatory STS maneuvers in response to a dementia-specific motor learning exercise program. This is the first study that demonstrated preserved motor learning abilities in PwD by using a motor skill highly relevant to everyday life.

AIDE-Acute Illness and Depression in Elderly Patients. Cognitive Behavioral Group Psychotherapy in Geriatric Patients With Comorbid Depression: A Randomized, Controlled Trial.

BACKGROUND: Comorbid depression is highly prevalent in geriatric patients and associated with functional loss, frequent hospital re-admissions, and a higher mortality rate. Cognitive behavioral psychotherapy (CBT) has shown to be effective in older depressive patients living in the community. To date, CBT has not been applied to older patients with acute physical illness and comorbid depression. OBJECTIVES: To evaluate the effectiveness of CBT in depressed geriatric patients, hospitalized for acute somatic illness. DESIGN: Randomized controlled trial with waiting list control group. SETTING: Postdischarge intervention in a geriatric day clinic; follow-up evaluations at the patients' homes. PARTICIPANTS: A total of 155 randomized patients, hospitalized for acute somatic illness, aged 82 ± 6 years and suffering from depression [Hospital Anxiety and Depression Scale (HADS) scores >7]. Exclusion criteria were dementia, delirium, and terminal state of medical illness. INTERVENTION: Fifteen, weekly group sessions based on a CBT manual. Commencement of psychotherapy immediately after discharge in the intervention group and a 4-month waiting list interval with usual care in the control group. MEASUREMENTS: HADS depression total score after 4 months. Secondary endpoints were functional, cognitive, psychosocial and physical status, resource utilization, caregiver burden, and amount of contact with physician. RESULTS: The intervention group improved significantly in depression scores (HADS baseline 18.8; after 4 months 11.4), whereas the control group deteriorated (HADS baseline 18.1; after 4 months 21.6). Significant improvement in the intervention group, but not in the control group, was observed for most secondary outcome parameters such as the Barthel and Karnofsky indexes. Intervention effects were less pronounced in patients with cognitive impairment or acute fractures. CONCLUSIONS: CBT is feasible and highly effective in geriatric patients. The benefits extend beyond effective recovery and include improvement in physical and functional parameters. Early diagnosis, good access to psychotherapy, and early intervention could improve care for depressive older patients. CLINICAL TRIAL REGISTRATION: www.germanctr.de German Trial Register DRKS 00004728.

The Association of Hyponatremia, Risk of Confusional State, and Mortality.

BACKGROUND: Hyponatremia and delirium are frequent problems in older hospitalized patients. Although confusional states are considered to be a possible complication of hyponatremia, there has been no systematic study to date of the precise prevalence of delirium among patients with hyponatremia and its effect on long-term outcomes. METHODS: In a 13-month period in 2009/2010, all patients with a serum sodium level less than or equal to 130 mmol/L (the hyponatremia group) in a cohort of hospitalized older patients were studied and compared to a normonatremic control group of patients who were matched for age, sex, and diagnosis group. The prevalence of delirium was determined by two-stage examination. Inhospital mortality, mortality six months after initial examination, and functional status were prospectively analyzed. RESULTS: 179 patients were identified whose serum sodium level was less than or equal to 130 mmol/L (7.9% of all treated patients), of whom 141 were included in the hyponatremia group. The mean age of the participants was 83 (range, 63-102), and 84% were women. Patients with hyponatremia suffered more often from delirium (22.7% versus 8.5%; p = 0.002) and had a higher inhospital mortality (10.6% versus 2.1%; p = 0.005). The mortality six months after initial examination was 31.9% versus 22.7% (p = 0.080). 59.7% of patients in the hyponatremia group and 49% in the control group (p = 0.146) needed a higher level of chronic care after discharge than they had needed before the hospitalization. CONCLUSION: Hyponatremia in hospitalized older patients is associated with a higher likelihood of delirium and an elevated in-hospital mortality.

Improvement in muscular performance and decrease in tumor necrosis factor level in old age after antioxidant treatment.

Aging-related loss of muscle function is a predictor of mortality and a surrogate parameter of the aging process. Its consequences include a high risk for falls, hip fractures, and loss of autonomy. Aging is associated with changes in the oxidant/antioxidant balance including a decrease in plasma thiol (cysteine) concentration. To assess the importance of cysteine, we determined in a double-blind study the effects of N-acetylcysteine on the functional capacity of frail geriatric patients and their response to physical exercise. The subjects on placebo showed only a relatively weak response, and 31% showed even a decrease in more than one parameter during the observation period. Low plasma arginine levels were correlated with a weak overall performance before exercise and a poor response to exercise. N-Acetylcysteine strongly enhanced the increase in knee extensor strength and significantly increased the sum of all strength parameters if adjusted for baseline arginine level as a confounding parameter. N-acetylcysteine had no significant effect on growth hormone and IGF-1 levels but caused a significant decrease in plasma TNF-alpha. These findings may provide a basis for therapeutic intervention and suggest that the loss of function involves limitations in cysteine and one or more other amino acids which may compromise muscular protein synthesis.

Cognitive impairment decreases postural control during dual tasks in geriatric patients with a history of severe falls.

OBJECTIVES: To investigate the influence of dual tasks, cognitive strategies, and fear of falling on postural control in geriatric patients with or without cognitive impairment and with a history of falls resulting in injury. DESIGN: Experimental three-group design. SETTING: Geriatric hospital. PARTICIPANTS: Twenty young healthy adults (mean age+/-standard deviation=25.4+/-4.4), 20 geriatric patients with a history of severe falls without cognitive impairment (mean age=82.6+/-5.5, mean Mini-Mental State Examination (MMSE) score=27.8+/-2.0) and 20 geriatric patients with a history of severe falls and cognitive impairment (mean age=83.2+/-5.5, mean MMSE=19.2+/-3.3). MEASUREMENTS: Motor performance: sway area and lateral and anterior-posterior sway angles. Cognition: semiautomated calculation steps (serial 2 forward) and nonautomated calculation derived from MMSE (serial 7 retro). Motor and cognitive performances were examined as single and dual tasks. Strategy decision, fear of falling, and subjective perception of motor and cognitive performance were assessed as covariates for dual-task performances. RESULTS: Motor performance decreased significantly during all dual tasks in geriatric patients with cognitive impairment and a history of falls resulting in injury. Cognitive performance was different depending on the task and group. Choice of cognitive strategies or fear of falling did not influence the dual-task performances. CONCLUSION: Even simple additional tasks substantially decrease postural stability due to attention-related cognitive deficits in cognitively impaired geriatric patients with a history of severe falls. The findings may help to explain the increased incidence and severity of falls in geriatric patients with cognitive impairment and a history of falls resulting in injury.

Psychological insulin resistance in geriatric patients with diabetes mellitus.

OBJECTIVE: To determine the extent to which geriatric patients with diabetes mellitus experience psychological insulin resistance (PIR). METHODS: A total of 67 unselected geriatric patients with diabetes (mean age 82.8±6.7 years, diabetes duration 12.2 [0.04-47.2] years, 70.1% female) were recruited in a geriatric care center of a university hospital. A comprehensive geriatric assessment (CGA) was performed including WHO-5, Hospital Anxiety and Depression Scale (HADS), Mini Mental State Examination (MMSE) and Barthel-Index. We assessed PIR using the Barriers of Insulin Treatment Questionnaire (BIT) and the Insulin Treatment Appraisal Scale in a face-to-face interview. RESULTS: Insulin-naïve patients (INP) showed higher PIR scores than patients already on insulin therapy (BIT-sum score: 4.3±1.4 vs. 3.2±1.0; p<0.001). INP reported in the BIT increased fear of injection and self-testing (2.4±2.4 vs. 1.3±0.8; p=0.016), expect disadvantages from insulin treatment (2.7±1.6 vs. 1.9±1.4; p=0.04), and fear of stigmatization by insulin injection (5.2±2.3 vs. 3.6±2.6; p=0.008). Fear of hypoglycemia, however, did not differ significantly (6.3±2.8 vs. 5.1±3.1; p=0.11). Depression was not shown to be a barrier to insulin therapy. CONCLUSION: INP with diabetes have a significantly more negative attitude toward insulin therapy in comparison to patients already on insulin. PRACTICE IMPLICATIONS: Systematic assessment of barriers of insulin therapy, individualized diabetes treatment plans and information of patients may help to overcome such negative attitudes, leading to quicker initiation of therapy, improved adherence to treatment and a better quality of life.

Sustainability of motor training effects in older people with dementia.

Evidence for sustainability of motor training effects in people with dementia is lacking. To examine whether the substantial improvements in motor performance achieved through a three-month specialized, standardized motor training were sustained, the participants of the randomized controlled trial were re-evaluated nine months after training had ceased. As part of a comprehensive study, participants with confirmed mild to moderate dementia underwent a progressive resistance and functional group training specifically developed for patients with dementia (intervention, n = 40) compared to a low-intensity motor placebo activity (control, n = 51). Primary and secondary outcome measures for maximal strength and function were measured before the start of the training (T1), directly after training ceased (T2), three months after training ceased (T3) and-the focus of this paper-nine months after training ceased (T4). Even after nine months without training, the gains in functional performance were sustained with significant group differences in the primary endpoint (five-chair-rise, relative change: IG: -8.54 ± 22.57 versus CG: +10.70 ± 45.89 s, p = 0.014, effect size ηp2 = 0.067). Other functional tests, such as walking speed and POMA (Tinetti), confirmed this result in the secondary analysis. Strength, as measured by the primary endpoint 1-Repetition Maximum (1RM) was still elevated (time effect for T1 versus T4: 148.68 ± 57.86 versus 172.79 ± 68.19 kg, p < 0.001, effect size ηp2 = 0.157), but between-group differences disappeared (relative change: maximal strength, IG: 22.75 ± 40.66 versus CG: 15.60 ± 39.26, p = 0.369). The study found that intensive dementia-specific motor training sustainably improved functional performance of patients with dementia nine months after cessation of training.