Neurogeriatrics-a vision for improved care and research for geriatric patients with predominating neurological disabilities.

Geriatric medicine is a rapidly evolving field that addresses diagnostic, therapeutic and care aspects of older adults. Some disabilities and disorders affecting cognition (e.g. dementia), motor function (e.g. stroke, Parkinson's disease, neuropathies), mood (e.g. depression), behavior (e.g. delirium) and chronic pain disorders are particularly frequent in old subjects. As knowledge about these age-associated conditions and disabilities is steadily increasing, the integral implementation of neurogeriatric knowledge in geriatric medicine and specific neurogeriatric research is essential to develop the field. This article discusses how neurological know-how could be integrated in academic geriatric medicine to improve care of neurogeriatric patients, to foster neurogeriatric research and training concepts and to provide innovative care concepts for geriatric patients with predominant neurological conditions and disabilities.

Refractory overactive bladder: a common problem?

INTRODUCTION AND HYPOTHESIS: Unsatisfactory treatment outcome sometimes is described as frequently occurring in patients treated with first-line therapy for overactive bladder (OAB). The present article reviews the different circumstances which may result in failure to respond to lifestyle interventions, behavioral therapy, and/or antimuscarinic treatment. METHODS: An extensive literature search was conducted to identify relevant articles on pathophysiological, clinical, and pharmacological aspects of refractory OAB. RESULTS: Missing definition, unrealistic individual expectation of treatment outcomes, lack of communication between physician and patient as well as pathophysiological and pharmacological processes were identified as relevant for failure to respond to first-line OAB treatment. Increase of patient's motivation to adhere to the prescribed treatment, critical examination of the patient in regard to the initial diagnosis, and individual adjustment of antimuscarinic therapy may be appropriate tools to improve treatment outcome in OAB patients. CONCLUSIONS: Overall, the incidence of refractory OAB seems to be overestimated. There are several approaches to improve therapy results.

[Urinary tract infections in the elderly]. / Harnwegsinfekte im Alter.

Acute infection of the urinary tract is one of the most commonly encountered bacterial infections in the frail elderly population and is responsible for substantial morbidity and recurrent infections with antibiotic resistance. Although generally considered to be self-limiting without treatment or easily treated with a short antibiotic regime, urinary tract infections (UTIs) often have a dramatic history, associated with incomplete resolution and frequent recurrence. The biological complexity of the infections combined with a dramatic rise in antibiotic-resistant pathogens highlight the need for an anticipating strategy for therapy necessary for a rapid recovery. The first crucial step is the classification in asymptomatic bacteriuria or complicated pyelonephritis, on which the decision for the intensity of treatment and diagnostic effort is based. For the selection of empiric antibiotic therapy, knowledge about the predominant uropathogens as well as local resistance patterns is important. In this manner, most urinary tract infections in the elderly can be treated without greater expense.

Top Ten Tips Palliative Care Clinicians Should Know About Urological Care.

Patients receiving palliative care (PC) can present with or develop a host of urological needs or complications. These needs can include attention to sexual health, urinary incontinence, genitourinary bleeding, and urinary tract obstruction by benign, malignant, or urinary stone diseases. These varied conditions require that PC clinicians understand invasive and noninvasive medical, surgical, and radiation options for treatment. This article, written by a team of urologists, geriatricians, and PC specialists, offers information and guidance to PC teams in an accessible "Top Ten Tips" format to increase comfort with and skills around assessment, evaluation, and specialist referral for urological conditions common in the PC setting.

[6 years of bladder blog: chances and benefits of a tool within the "new media"]. / 6 Jahre Blasenblog: Chancen und Nutzen eines Tools in den neuen Medien.

INTRODUCTION: Web-based information about urinary incontinence is rather rare, especially including features of a "blog" with periodically published "teasers", small informative articles for patients. The contemporary blog "the bladder" is operated by Dr. Pfleger, Bamberg and attended by Prof. Dr. A. Wiedemann and Dr. G. Naumann as consulting experts. Acceptance and status of the "bladder blog" should be re-assessed. METHODS: 6 years after the start of the project and 2 years after the relaunch of the underlying homepage the ranking of the blog in web-based keyword-searches was analyzed. Included questions, the blog-teasers and their effect in the ranking in Google results were evaluated with "Google Analytics" and other analysis tools with the items "position" (average position in Google results of all requests leading to the bladder blog), "impression" (frequency of mentioning the blog in Google results) and the "click-through rate" (pro-active visits of the homepage after being shown in Google in relation to the "impressions").November 2018 served as the reference month. RESULTS: 38 keywords that were really entered by users and reached at least 20 clicks lead to a number 1 ranking in Google results, further 60 keywords lead to a result within the first 10 notifications in Google. These resulted in a high click-through-rate - the real view of the blog homepage after being simply indicated by Google. The website had a total of 30,669 pageviews in November 2018. The highest amount of clicks and impressions was recorded by the blog-article "suprapubic or transurethral" 1344 clicks und 21.357 impressions. In total, 164 questions within the blog were collected. These dealt predominantly with the topics "urinary incontinence" and "overactive bladder" and were predominantly posed by females (92 female, 38 male, 34 not evaluable by considering the nickname). 33 questions led to an inquiry-response circle containing up to 7 steps. The questions often showed a severe and complicated disease (e. g. complete urinary loss 4 weeks after hysterectomy which should be awaited) or an incomprehensible lack of diagnostic tools ("my doctor is convinced to deal with a therapy resistant overactive bladder after several pharmaceutic attempts only by anamnestic information and urine analysis). CONCLUSION: The "bladder blog" is a more and more intensively used, low-threshold information tool predominantly used by females around the topic "urinary incontinence". Regularly published blog-articles succeed in highly relevant results in Google searches. The incoming questions often show a severe and complicated disease and sometimes - as analyzable in the questions - a lack of expertise of the practitioners.

[Are there benefits for catheter valves for catheter-associated quality of life? : Results of an investigation in 427 catheter wearers with life-long indication]. / Hat eine Ventilversorgung Vorteile bei der katheterassoziierten Lebensqualität? : Ergebnisse einer Untersuchung an 427 Katheterträgern in lebenslanger Indikation.

BACKGROUND: In urology, a subset of patients with lifelong urine drainage are fitted with a catheter valve. Data on catheter-related quality of life (crqol) in this subset of patients are missing. AIM: Clarification of the whether there are advantages for valve-aided catheters in comparison with continuous urine drainage in catheter wearers with a lifelong indication. METHODS: In all, 357 patients with a catheter with lifelong indication of continuous urine drainage from a previous study were compared with 70 valve-aided patients. The crqol was evaluated by a validated assessment with 25 items and five domains. RESULTS: There were statistically more patients with a suprapubic catheter than with a transurethral indwelling catheter (73.4 vs. 54.4%, p = 0.005), significantly more patients with bladder voiding dysfunction (73.5 vs. 52.6%, p = 0.003) and significantly more patients with small catheter sizes (p = 0.001). Crqol was altogether slightly impaired with a median score of 4.2 (no impairment indicated by 5 points) in valve-aided patients, but crqol was more impaired in valve-aided patients compared to patients with continuous drainage (4.4 points, n. s.). Some items demonstrated more problems dealing with urinary urge in valve-aided patients, but catheter-related pain was more often worse in patients with continuous drainage. CONCLUSION: There is no clear evidence for an advantage of a catheter valve over a continuous urine drainage system. Thus, the decision regarding a catheter-valve system must be made individually according to the indication and the preferences of the patient.

[Oral therapy for interstitial cystitis: pentosan polysulfate sodium]. / Orale Therapie der Interstitiellen Zystitis: Pentosanpolysulfat-Natrium.

INTRODUCTION: It is currently assumed that interstitial cystitis/bladder pain syndrome is caused by damage to the glycosaminoglycane layer on the urothelium of the urinary bladder. This layer can be repaired by oral therapy with pentosan polysulfate sodium. The focus of this article is on the history of this drug, its efficacy, its valuation in guidelines and especially the possible correlation with maculopathy. METHODS: Literature research in PubMed and Embase. RESULTS: PPS has a US and European approval for the therapy of IC characterised by glomerulations or a Hunner lesion detected by endoscopy and bladder distension. Its efficacy was proven in randomised trials. This led to a recommendation as a basic pharmaceutical therapy (in addition to behavioural intervention, dietary therapy or other drug treatments such as pain therapy). After a treatment period of six months, efficacy should be re-evaluated. Side-effects include mild haemodilution, nausea and loss of hair. Two publications of a US eye clinic have recently postulated a correlation between prolonged high-dose therapy with PPS and a special kind of maculopathy. Although this correlation was rejected in a large-scale health service study in Germany, a "red-hand-letter" led to the recommendation to perform an ophthalmologic examination before and during the treatment with PPS. Due to a pending litigation between payers and the distributor, PPS is currently out of trade in Germany. However, PPS can still be prescribed but must be imported from adjacent European countries. Unfortunately, these modalities have led to a significant undersupply of patients with IC/BPS. It is feared that this undersupply will increase further as the litigation is ongoing. CONCLUSION: Being the only causally acting compound in the therapy of IC/BPS, PPS has an exceptional status. Although an ongoing litigation is pending in Germany and the correlation with maculopathy is still unclear, PPS must remain part of the current and future therapy of IC/BPS.

[Adverse drug reaction affecting the urinary tract - the Witten urinary tract adverse reaction score]. / Unerwünschte Arzneimittelwirkungen am Harntrakt ­ der Wittener Harntrakt-Nebenwirkungs-Score.

The urinary tract is the site of many adverse drug reactions, including the formation of residual urine, urinary retention, pollakisuria, polyuria, nycturia, detrusor stimulation, detrusor inhibition, haematuria, dysuria and other symptoms. Nevertheless, there is no general overview or evaluation of the substances that can trigger these adverse drug reactions. The available lists of "potential inadequate medication" either focus on a pharmacological group of adverse reactions ("anticholinergic burden score"), a group of drugs for a specific indication (LUTS-Forta) or on a selected group of patients (PRISKUS List, Beers List).The following interdisciplinary project has been processed by the group for urogeriatrics in the University of Witten/Herdecke and is intended to fill this gap. We have identified substances which can in principle trigger adverse reactions in the urinary tract - according to a variety of databases. We also categorise the available literature (case reports, case series, RCT, meta-analysis) and present a structured analysis of the risk by 33 experts. This results in a list of 235 substances that can lead to various different adverse reactions of the urinary tract. This list includes a "theoretical" score from the reports in the databases or the corresponding literature, a "practical" score based on an expert evaluation of clinical reality and a cumulative score, classified in accordance with the Rote Liste".It is now possible to classify the extent to which newly prescribed drugs may pose a risk of adverse reactions in different patients. Conversely, this may also help to clarify whether a functional disorder of the urinary tract is fully or partially linked to treatment with a specific drug. We plan to develop an app to assess adverse drug reactions in the urinary tract.

[Is it possible to avoid a life-long suprapubic catheter in geriatric patients with urinary retention or overflow incontinence by a simultaneous GreenLight laser procedure?] / Lässt sich eine dauerhafte Katheterversorgung bei geriatrischen Patienten mit Harnverhalt oder chronischer Harnretention durch eine 180-W-XPS-Greenlight-Lasertherapie der Prostata vermeiden?

INTRODUCTION: This study aims to analyse the impact of a simultaneous 180-Watt XPS™ GreenLight laser treatment of the prostate in addition to an initially planned sole placement of a suprapubic catheter in geriatric patients initially hospitalised only for the purpose of the latter procedure. METHODS: A retrospective analysis was carried out on 48 patients undergoing both procedures simultaneously over an 18-month period (1/2015 - 6/2016). RESULTS: On admission, the examined patients (mean age 72.46 years) had a mean ISAR score of 2.5 (0 - 6) points indicating a need for geriatric care. These patients had a mean number of 7.676 (2 - 27) diagnoses and took a mean of 6.77 drugs (0 - 14) according to the discharge report. The mean residual urine volume was measured to be 600 (300 - 2,800) ml preoperatively with a mean prostate size of 38 ccm (35 - 75 ccm). In 63.2 % of these patients, the removal of the suprapubic catheter was possible after a mean period of 52.39 (3 - 365) days in an outpatient setting. Factors predicting successful catheter removal were "geriatric issues" such as the ISAR score on admission (p = 0.001), number of diagnoses stated in the discharge letter (p = 0.023), number of diagnoses recorded in the DRG database (p = 0.002), number of drugs stated in the discharge letter (p = 0.015), "assistance needed" (p = 0.001) and "living in a nursing home" (p = 0.008). Any additional concomitant medication exceeding the mean value of 6.77 drugs in the discharge report lowered the chance of catheter removal by 50 %. CONCLUSIONS: In 63.2 % of patients, lifelong bladder drainage was avoided by simultaneous 180-Watt XPS GreenLight laser treatment administered additionally to the placement of a suprapubic catheter. This has a positive impact on quality of life, avoidance of catheter complications and long-term costs. Factors predicting a successful catheter removal were geriatric aspects such as ISAR score, multimorbidity and multimedication. These factors indicate a need to introduce geriatric aspects and methods in urology.

[Preoperative PSA levels and development of PSA after 180-W XPS greenlight laser treatment of the prostate: what is the reality in clinical routine practice?] / Präoperative PSA-Werte und PSA-Verlauf nach 180-Watt-XPS-Greenlight-Laserung der Prostata ­ wie ist die Realität im klinischen Alltag?

INTRODUCTION: The aim of this retrospective study was to evaluate preoperative levels of PSA (prostate-specific antigen) and the postoperative development after 180-W XPS™ greenlight laser treatment of the prostate under real-world conditions. METHOD: Preoperative PSA levels were evaluated in 749 patients undergoing a 180-W XPS greenlight laser procedure from 2012 to 2017 in Witten, Germany, in relation to age, volume of the prostate, urinary tract infection, Foley catheter and co-morbidities. The postoperative development of PSA was identified by retrieving PSA levels from general practitioners or urologists. RESULTS: The average age of the patients was 73.33 ±â€Š9.26 years. The prostate volume measured by rectal ultrasound was 42.42 ±â€Š18.33 ml. Median preoperative PSA was 2.59 ng/ml. In 268 patients (35.8 %), the PSA level was above 4 ng/ml. It was evaluated by prostate biopsy in 106 patients (39.6 %). 6 months after the surgical procedure (n = 86), PSA decreased to 1.25 ng/ml and increased slightly to 1.46 ng/ml after 12 months (n = 126). Logistic regression analysis demonstrated that a PSA level elevated to more than 4 ng/ml preoperatively is related to prostate volume (p = 0.001) the existence of a transurethral Foley catheter (p = 0.002), but not to age (p = 0.349), the existence of a suprapubic catheter (p = 0.207), an infection of the lower urinary tract (p = 0.966) and the number of co-morbidities mentioned in the discharge letter (p = 0.936). DISCUSSION: In line with expectations and clinical trials, there was a postoperative decrease of PSA by more than a half of the preoperative value. Significant factors related to preoperative elevation of the PSA level were prostate volume, a transurethral Foley catheter instead of the suprapubic type of catheter and a urinary infection. Although elevated PSA levels were seen in about one third of patients, evaluation by prostate biopsy was only performed in 39.6 % of these patients due to their performance status and other clinical issues.

[Comparison of 180 W Greenlight-XPS laser vaporisation and transurethral resection of the prostate: comfort for patients and healthcare staff in clinical routine practice]. / Vergleich von 180-Watt-XPS-Greenlight-Laserung und transurethraler Elektroresektion der Prostata: Patienten- und Personalkomfort in der klinischen Routine.

BACKGROUND: Transurethral resection of the prostate (TUR-P) is considered the gold standard in the surgical treatment of symptomatic benign prostatic hyperplasia. Besides the conventional TUR-P, there are numerous technological modifications of the procedure. An increasing use of the 180 W Greenlight-XPS™ laser vaporisation of the prostate (GLL) has been observed recently. OBJECTIVE: TUR-P and GLL have already been studied for safety, efficacy and economy. The aim of the present study was to analyse patient-related postsurgical aspects such as patient comfort and pain. METHODS: A total of 250 consecutive patients (100 TUR-P and 150 GLL) were analysed by examining anonymised medical records. Information on resection weight (TUR-P), applied energy (GLL), prostate volume, antiplatelet/anticoagulant therapy, catheter size, length of catheterisation, length of bladder irrigation, length of hospital stay and postoperative pain score was gathered. RESULTS: The prostate volume was comparable between the two procedures (p = 0.434). The proportion of patients with ongoing antiplatelet and anticoagulant therapy was significantly higher with GLL (p < 0.0001). The catheter size was comparable with no statistical difference (p = 0.102). Length of catheterisation and duration of bladder irrigation were significantly shorter with GLL (p = 0.016 and p = 0.01). While the length of hospital stay was not statistically different (p = 0.233), a tendency to shorter hospital stays was seen with GLL. A similar postoperative pain score was observed with a low pain level in general and the highest scores being recorded shortly after the procedure. CONCLUSIONS: The results demonstrate that GLL - a procedure preferably used for patients with ongoing antiplatelet and anticoagulant therapy - provides a high experience of postoperative comfort and offers potential for savings in terms of nursing resources (duration and intensity of bladder irrigation).

[Does intravesical application of botulinum toxin lead to systemic muscle weakness? An approach to an uro-geriatric problem]. / Gibt es eine systemische Muskelschwäche nach intravesikaler Botulinumtoxin-Behandlung? Eine Annäherung an ein uro-geriatrisches Problem.

INTRODUCTION: Muscle weakness after botulinum toxin injection into the detrusor muscle due to refractory overactive bladder is reported by approximately 10 % of patients in clinical studies. This could further aggravate the risk of falls in geriatric patients. For the first time, the potential problem of muscle weakness after urologic treatment with botulinum toxin was to be investigated by a geriatric assessment (hand grip measurement). MATERIAL UND METHOD: In a prospective study design, hand grip was measured before and three months after botulinum toxin injection into the urinary bladder in a dose of 100 - 200 MU. The measurement was performed with the usual hand grip device by pressing the pressure gauge three times with the dominant hand. Relevant muscle weakness was assumed if hand grip was reduced by more than 20 %. The measurement of 100 patients was intended. RESULTS: In an interim analysis of 53 patients with an average age of 65.25 ±â€Š13.99 years, the decrease in hand grip was + 0.00 ±â€Š0.06 kPa or -0.13 ±â€Š1.69 %. In patients receiving 100 MU of botulinum toxin, the decrease was +0.01 ±â€Š0.06 kPa or -0.29 ±â€Š1.64 %; after injection of 200 MU, it was 0.02 ±â€Š0.06 kPa or 0.720 ±â€Š1.77 %. The changes were neither significant for the overall population nor for the differences between the dosage groups. Therefore, the study was terminated. CONCLUSION: The results of the hand grip measurement performed after botulinum toxin injection into the detrusor muscle demonstrated for the first time that there is no loss in hand grip as a possible indicator of muscle weakness and a risk of falls after urologic treatment with 100 MU or 200 MU. Accordingly, the botulinum toxin injection due to refractory overactive bladder seems to be safe for geriatric patients.

Impact of stroke volume on motor outcome in neonatal arterial ischemic stroke.

BACKGROUND AND OBJECTIVES: Neonatal arterial ischemic stroke (NAIS) can lead to long-term neurological consequences such as cerebral palsy (CP). The aim of this study was to evaluate the predictive value of acute diffusion-weighted imaging (DWI) for CP by analyzing stroke volume next to brain structure involvement. METHODS: We included 37 term-born infants with NAIS prospectively registered in a nationwide pediatric stroke registry. DWI was performed between 0 and 8 days (mean 3 days) after stroke manifestation. Participants were neurologically assessed at the age of 2 years. We calculated the stroke volume (in mm3) and the ratio of the stroke volume to the volume of the entire brain (relative stroke volume). The predictive value of the relative stroke volume was analyzed and an optimal threshold for classification of children with high- and low-rates of CP was calculated. Predictive value of brain structure involvements and the prevalence of CP in combinations of different brain structures was also assessed. RESULTS: Sixteen children (43.2%) developed CP. Relative stroke volume significantly predicted CP (p < .001). Its optimal threshold for division into high- and low-rate of CP was 3.3%. The basal ganglia (OR 8.3, 95% CI 1.2-60.0) and basis pontis (OR 18.5, 95% CI 1.8-194.8) were independently associated with CP. CONCLUSION: In addition to determining the involvement of affected brain areas, the volumetric quantification of stroke volume allows accurate prediction of cerebral palsy in newborns with NAIS.

[S2e guideline "Urinary incontinence in geriatric patients": a summary]. / S2e-Leitlinie "Harninkontinenz bei geriatrischen Patienten" ­ eine Zusammenfassung.

In 2009, the first complete guideline for the diagnostic evaluation and treatment of urinary incontinence in geriatric patients, commissioned by the German Society of Geriatrics, was developed by the working group Urinary Incontinence and published in the guideline registry of the AWMF (Association of the Scientific Medical Societies in Germany). We are presenting an up-to-date summary of the most recent update published as an "S2e" guideline in January 2019. This is the only valid, up-to-date and complete guideline on urinary incontinence in German language. Each chapter was reviewed with a special focus on matters relevant to very old patients, i. e. multimorbid patients over 75 years of age or patients older than 80 years, all of whom, due to their particular vulnerability, are at risk of chronification and loss of autonomy. The chapters "Assessments", "Medicinal therapy", "Behavioural intervention", "Physiotherapeutic interventions" and "Therapeutic appliances" have been revised completely. In addition, the guideline now also includes an evaluation of the ß3-mimetic drug Mirabegron as well as a chapter on long-term urinary bladder drainage with a suprapubic or transurethral catheter including a review on the differential indication and possible consequences or complications.

[The ISAR-positive patient in urology]. / Der ISAR-positive Patient in der Urologie.

BACKGROUND: Since 2015 so-called "ISAR Screening" (Identification of Seniors at Risk) is mandatory for patients older than 75 years being hospitalised in Germany. It remains unclear how these patients identified as suffering from geriatric diseases are further characterised in urology and how this information is applied in the ongoing clinical treatment. METHODS: From the July 1st to December 31th 2016, 337 patients older than 75 years were subjected to ISAR-screening. The result ("with or without need for geriatric action") was contrasted with the results of further assessments, such as the assessment of the risk of falls, the risk of developing a pressure ulcer or malnutrition, demographic data (e. g. age, hospitalisation status) and urological diagnoses. RESULTS: 102 of 377 Patients were tested as "ISAR-positive" during the period of examination. These patients were significantly older than "ISAR-negative" patients. Additionally, ISAR-positive patients had a significantly higher risk of falling, developing pressure ulcers or malnutrition and were significantly more frequently hospitalised under emergency conditions. Reflecting their multimorbidity, ISAR-positive patients had significantly more diagnoses than ISAR-negative patients. These diagnoses were dominated by oncological and infectious urological diseases. Whereas most of the patients were screened by ISAR-screening according to the entire process, the subsequent assessment was performed in fewer patients. CONCLUSION: The ISAR-screening identifies the "geriatric" patient in urology, who is threatened by his vulnerability, chronification, loss of autonomy and multimorbidity when being hospitalised. The regular implementation of the systemic approach of applying ISAR-screening and the further assessments into the clinical daily routines of urology constitute the major challenge in the future.

[Urinary incontinence in geriatric patients: Continence products, specialized continence nurses and indwelling catheter]. / Harninkontinenz bei geriatrischen Patienten: Hilfsmittel, qualifizierte Pflegekraft und Harnblasenlangzeitdrainage.

INTRODUCTION: 1/2019 we presented an update of the AWMF guideline 'urinary incontinence in frail elderly - diagnostics and therapy'. Since its introduction in 2015 the guideline has been under a continuous revision process by the working group 'Incontinence' of the German Society for Geriatrics (DGG). From this guideline which is accredited as an official guideline of the DGG we present here the chapter about continence products, specialized continence nurses and indwelling catheter. METHODS: A profound literature search was done in a structured evaluation process in the context of a 'frail elderly'. Most medical societies define a 'frail elderly' as someone older than 70 years and multimorbide or older than 80y. We focused on randomized, double blind, placebo controlled studies as well as already published guidelines in this field. In the case no studies were available or not feasible other publications such as not randomized studies or case reports were taken into consideration for our guideline. Recommendations resulted from a structured voting process and the results are stated as percentage of members who agreed. RESULTS: In case of failed or not wanted incontinence treatment, options like an indwelling transurethral or suprapubic catheter or a condom catheter in men maybe the best transient or definite solution. Trained specialized continence nurses have proven to be beneficial in conservative treatment modalities, such as toilet training or measuring residual urine. They can further consult patients and carers to enhance physical environment to reduce incontinence. CONCLUSION: Especially in institutions caring for frail elderly a coordinated care of specialized a multidisciplinary setting of continence nurses and doctors are beneficial for those affected. Under certain conditions palliative treatment should be included in geriatric incontinence care.