Prospective evaluation of renal function, serum vitamin D level, and risk of fall and fracture in community-dwelling elderly subjects.

SUMMARY: This prospective study in elderly showed that kidney function plays a minor role in explaining the high prevalence of vitamin D deficiency seen in noninstitutionalized elderly subjects. However, 25-hydroxyvitamin D levels were clearly inversely associated with risk for first fall, which was especially seen in subjects with calcium levels above median. INTRODUCTION: Few prospective studies in elderly exist that have investigated the association of renal dysfunction and vitamin D status on risk of falls. The aim of this study is to evaluate the association of renal function with 25-hydroxyvitamin D (25-OH-D) levels and, secondly, to assess the role of both factors on the risk of falls and subsequent bone fractures. METHODS: This is a prospective population-based cohort study among noninstitutionalized elderly subjects during a 1-year follow-up. 25-OH-D levels and renal function were estimated, the latter by cystatin C-based equations. Information on falls was assessed prospectively. RESULTS: Overall, 1,385 subjects aged 65 and older were included in the study (mean age 75.6 years), of whom 9.2 % had a 25-OH-D serum level above 75 nmol/L (US units 30 ng/mL); 41.4 %, between 50 and 75 nmol/L (US units 20 to 29 ng/mL, insufficiency); and 49.4 %, <50 nmol/L (US units <20 ng/mL, deficiency). We found no association of chronic kidney disease with risk of first fall. In contrast, 25-OH-D serum categories were clearly associated with risk of first fall and we found evidence of effect modification with calcium levels. In the group with a calcium level above the median (≥ 9.6 mg/dL), subjects with 25-OH-D serum level between 50 and 75 nmol/L and with concentrations <50 nmol/L had a hazard rate ratio (HRR) of 1.75 (1.03-2.87) and 1.93 (1.10-3.37) for risk of first fall. 25-OH-D serum levels were also associated with several markers of inflammation and hemodynamic stress. CONCLUSIONS: We demonstrated an association of 25-OH-D serum levels and risk of first fall, which was especially evident in subjects with serum calcium in upper normal, independent of renal function.

Self- and proxy report for the assessment of pain in patients with and without cognitive impairment: experiences gained in a geriatric hospital.

BACKGROUND: Pain assessment is a complex procedure in patients with different degrees of cognitive impairment. The challenge is to determine whether self-reporting tools are adequate and to identify the cases in which proxy ratings are necessary. PATIENTS AND METHODS: As part of an open, prospective observational study, 178 patients underwent a comprehensive pain assessment consisting of the Numeric Rating Scale (NRS), the Verbal Rating Scale with four and five items (VRS4 and VRS5) and the Pain Assessment in Advanced Dementia Scale (PAINAD). RESULTS: Even without prior knowledge of a patient's cognitive impairment, this toolkit can be used to reliably identify cases where self-rating is appropriate and where proxy rating becomes necessary. Inter-rater reliability: "good" agreement [Cohen's κ = 74.2% (p < 0.001) (95%CI, 54.6-93.8%)], test-retest reliability: "moderate" agreement [κ = 55.3% (p < 0.001) (95%CI, 28.5-82.1%)]. Furthermore, movement resulted in a higher correlation between the selected assessments. Self-report assessments are appropriate up to a mini-mental state examination (MMSE) value greater than ten. In comparison to NRS, VRS4 and VRS5 remain more stable as the degree of cognitive impairment increases. CONCLUSIONS: In the majority of the cases, our approach enables reliable appropriate pain assessment without the strict prerequisite of an upstream cognitive assessment.

Actigraphic daytime activity is reduced in patients with cognitive impairment and apathy.

OBJECTIVES: Apathy is a neuropsychiatric symptom in mild cognitive impairment (MCI) and dementia. This study examines correlations between Apathy Evaluation Scale (AES) ratings and actigraphic measures of daytime activity. The aim of this study is to determine the value of ambulatory actigraphy in the assessment of locomotor deficits as a correlate of apathy in geriatric patients with cognitive impairment. PATIENTS AND METHODS: In this cross-sectional study a total of 82 participants were recruited, 32 patients with dementia, 21 patients with MCI and 23 elderly controls. Rating scales for apathy (AES) and depression (Beck Depression Inventory, BDI) were completed. To measure daytime activity a wrist-worn actigraph and an established protocol were used. A single measure of mean daytime activity per participant was calculated for further statistical analysis. RESULTS: In the two groups of patients with MCI and dementia, apathy is associated with reduced daytime activity, independent of diagnosis (no group by apathy interaction). AES scores correlate significantly with daytime activity. Cognitive impairment reduces daytime activity (effect greater in dementia than in MCI). Daytime activity is negatively correlated with memory deficits. CONCLUSION: Ambulatory actigraphy is a promising method to evaluate self-initiated action as a correlate of apathy in patients with cognitive impairment.

The grapes of war. Somatoform pain disorder and history of early war traumatization in older people.

Persistent pain is not a normal part of aging. Nevertheless, many older patients have long-lasting, more or less medically unexplained pain symptoms and, consequently, are often severely disabled, incur high health care costs, and have high comorbidity rates. Moreover, the effects of early traumatization, especially due to wars, and even below the level of posttraumatic stress disorder (PTSD) are apparent. However, the developmental and neurobiological underpinnings of somatoform pain disorder, especially in pain-prone elderly patients, and its correlations with a history of war traumatization even decades after the incident remain unclear. Furthermore, a management strategy for this disorder tailored to older people and their special needs is lacking. Adequate therapeutic regimens such as adjusted psychotherapeutic procedures for elderly patients can only be promoted through a better understanding of the neurobiological and biographical underpinnings of this still controversial disorder.

Physical activity and other health-related factors predict health care utilisation in older adults: the ActiFE Ulm study.

BACKGROUND: Health care utilisation (HCU) can be a useful outcome for estimating costs and patient needs. It can also be used as a surrogate parameter for healthy ageing. The aim of this study was to analyse the associations of formerly described and potentially new parameters influencing health care utilisation in older adults in Germany. PATIENTS AND METHODS: The ActiFE Ulm (Activity and Function in the Elderly in Ulm) study is a population-based study in 1,506 community dwelling older adults aged 65-90 years in Ulm and surrounding areas in southwestern Germany. Between March 2009 and April 2010 a full geriatric assessment was performed including accelerometer-based average daily walking duration, comorbidity, medication, physical and psychological functioning, health care utilisation, sociodemographic factors etc. The association between above named measures and health care utilisation, represented by the number of drugs, the days in hospital and the number of physician contacts over one year was calculated in multiple regression models. Analysis was conducted among subjects with complete information (n = 1,059, mean age 76 years, 55% male). RESULTS: The average number of drugs was 4.5 and over 95% of participants visited a physician at least once a year while still more than 65% contacted their physician more than twice a year. Reduced physical activity, BMI, self-rated health and/or comorbidity and male sex were the best predictors of health care utilisation in community dwelling older adults when looking at both the number of drugs and the number of physician contacts over 12 months together. With regard to single diseases entities the best predictors of both the number of drugs and the number of physician contacts were asthma, chronic obstructive pulmonary disease (COPD)/chronic bronchitis and chronic neurological diseases (mostly Parkinson's disease). The number of drugs was most strongly associated with coronary heart disease, diabetes, and high blood pressure. CONCLUSION: Reduced walking activity, self-rated health and/or comorbidity and male sex are the best predictors of health care utilisation as measured by the number of drugs and number of physician contacts over 12 months. Walking activity could be regarded as the most promising modifiable predictor of HCU in older adults.

[Maintenance of health and relief for caregivers of elderly with dementia by using "initial case management": experiences from the Lighthouse Project on Dementia, Ulm, ULTDEM-study]. / Gesunderhaltung und Entlastung pflegender Angehöriger von Demenzkranken durch ein "initiales Case Management": Erfahrungen aus dem Ulmer Leuchtturmprojekt Demenz (ULTDEM-Studie).

BACKGROUND: When facing the well-known demographic development with an increasing number of people suffering from dementia, there is a need of programmes to support nursing relatives and care at home. Many support services have been established in the past few years but they are rarely used by the relatives and the patients. The purpose of the Lighthouse Project Ulm (ULTDEM Study) was to prove the effectiveness of a single advisory approach in order to provide support services after care level classification and to relieve the burden placed on relatives caring for family members suffering from dementia ("initial case management"). METHODS: The ULTDEM Study is a prospective, open, randomized, controlled, interventional study with different parallel outcome measures (burden of caring, quality of life and mood). After the randomization, the interventional group was given comprehensive, individual advice about available treatment possibilities for dementia patients. Control group participants received standard treatment. Inclusion criteria were application of a care level (0 or 1) as well as dementia diagnosis. All participants (patients/relatives) underwent an initial and a 6 month comprehensive assessment. RESULTS: Our results show that a single advisory approach does not lead to a significant difference in outcome measures in interventional and control groups. Those tendencies described have to be interpreted as clinically not relevant. Although utilization of support services increases, it remains similar in both study groups. A confirmatory interpretation has not been possible due to a lack of adjustment to the findings regarding multiple testing and an insufficient degree of recruitment. Possible causes will be discussed such as premature intervention during the course of the disease, a lack of intervention blinding, recruitment bias and lack of an influence on adherence with regard to the use of support services. IMPLICATIONS: The study demonstrates that there is a substantial information deficit for persons affected by dementia and their relatives. Innovative ways still have to be developed to ensure that this information actually reaches the target audience.

Physical activity for the prevention of cognitive decline: current evidence from observational and controlled studies.

A sedentary life style has been associated with different types of dementia in several cross sectional, longitudinal, and case-controlled studies. However, randomized controlled trials that support this relationship are rare, have rather few participants, and mainly focus on physical (usually aerobic) exercise. The benefit of an increased physical activity (PA) has been mainly demonstrated for the prevention of Alzheimer's disease and vascular dementia, less so for other dementia types such as Lewy body dementia or frontotemporal dementia. The clinical evidence builds on a significant amount of animal research pointing to potential mechanisms as to how PA relates to cognitive function. While most studies have investigated singular interventions, others have studied the combination of both mental and physical activity to improve cognition or delay decline. However, questions remain such as what type and how much PA is beneficial? This review gives an overview of the current evidence on the clinical and epidemiological level and tries to answer these questions.

Pain and dementia: a diagnostic challenge.

PURPOSE: The aim was to present current knowledge about pain assessment in people with dementia and to discuss special challenges and possible solutions. METHODS: A literature search in MEDLINE® was performed. RESULTS: Due to the changing demographics of an aging population, an increasing number of people with dementia is expected. Many of these people will simultaneously suffer pain. Under-detection and under-treatment of pain in persons suffering from dementia is often described. As dementia progresses, the ability of the sufferer to verbally communicate his/her pain is often compromised, complicating the task of recognizing and treating pain. To improve pain recognition in dementia, many pain assessment tools have been developed. However, psychometric properties have to date been insufficiently examined. IMPLICATIONS: Self-report ratings should be performed as long as justifiable. Behavioural pain assessment tools should be used in advanced dementia despite their current imperfections: in particular, the PAINAD for daily use and the PACSLAC at longer intervals. All available additional information about pain should be considered.

[Implementation of a palliative care concept in a geriatric acute care hospital]. / Die Implementierung eines Palliativkonzepts in ein geriatrisches Akutkrankenhaus.

To integrate palliative care patients into an acute geriatric ward requires extensive and continuous education and preparation of all participating professionals. It can be a lengthy process to integrate palliative care concepts despite cooperation of the hospital administration. The group of patients to be integrated differs from the patients of regular geriatric wards because of a higher percentage of relatively young oncologic patients and they differ from a regular palliative ward because about 50% are non-oncologic patients, while the average age is much higher than in normal palliative care. It is possible to integrate specialized palliative care into a regular geriatric ward. Patients admitted without palliative intention will benefit the most from ward-integrated palliative care if the treatment aim turns this way. Ward-integrated palliative care can be an integral part of treating geriatric patients in addition to acute geriatric medicine, rehabilitation, and prevention. It can also provide caretakers and patients with the benefits from continuity of treatment and care.

Fractures after nursing home admission: incidence and potential consequences.

SUMMARY: Fracture rates were examined in residents newly admitted to nursing homes. The risk of a fracture was highest during the first months after admission and declined thereafter. This risk pattern was observed independently of fracture site, gender or degree of care need. INTRODUCTION AND HYPOTHESIS: Residents of nursing homes are a high-risk group for fractures. The aim of the study was to analyse fracture rates as a function of time from admission to nursing home. METHODS: Fractures of the upper limb, femur, pelvis and lower leg, time to first and subsequent fractures, age, gender and care needs at admission were measured in 93,424 women and men aged 65 years and over and newly admitted to nursing homes in Bavaria between 2001 and 2006. RESULTS: Fracture incidence was highest during the first months after admission to nursing homes and declined thereafter. This pattern was observed for all fracture sites, in women and men and in residents with different care needs. For example, fracture rates of the upper limb declined from 30.0 to 13.5/1,000 person-years in the first 9 months after admission and for all fracture sites from 135.3 to 69.4/1,000 person-years in a corresponding time period. CONCLUSION: Newly admitted residents have the highest fracture risk. The pattern of risk is similar across all fractures, suggesting a generic causal pathway. Implementation of effective fracture prevention efforts should be a priority at the time of admission to nursing homes.

[Reliability of the abbreviated version of the Late Life Function and Disability Instrument--a meaningful and feasible tool to assess physical function and disability in the elderly]. / Reliabilität der deutschen Kurz-Version des "Late Life Function and Disability Instrument". Ein sinnvoller und praktikabler Fragebogen zur Bestimmung der körperlichen Funktion und Beeinträchtigung älterer Personen.

BACKGROUND: The early assessment of prevalent disability and functional decline is of increasing importance for prevention issues and for the evaluation of change in clinical studies. The assessment of common daily tasks and resulting disability is essential for a complete impression of a patient's capabilities. There are plenty of instruments that cover basic and instrumental activities of daily living by assessing the person's dependence at a specific functional task. However, the early stages of everyday life limitations and functional decline are usually not being captured. In this article we have examined psychometric properties of the German adaptation of the abbreviated "late life function and disability instrument", a promising tool that is capable of capturing early aspects of functional decline and disability. METHODS: Older Caucasian men and women (Median=82 years) with a wide range of functional status (Short Physical Performance Battery: Median=6, Min.=0, Max.=12) completed the abbreviated version of the LLFDI once (n=173). A subgroup was assessed twice to examine interrater (n=13) and intrarater (n=10) reliability. Cognitive and functional status was assessed at baseline. RESULTS: Internal consistency (Cronbach's ) was acceptable for the personal role and social role of the frequency items of the disability component (0.55 to 0.62) and very good for all other parts of the instrument (0.78 to 0.89) without a significant difference when compared for overall cognitive performance or executive function. Test-retest reliability was very good (0.81 to 0.96) and interrater reliability was acceptable to very good (0.62 to 0.96) with only acceptable results for the limitation items of the disability component. The total scores of the two components did not demonstrate significant floor or ceiling effects and the interview lasted on average 17 minutes (range 8 to 35 min). INTERPRETATION: The German adaptation of the abbreviated version of the "Late Life Function and Disability Instrument" has minimal ceiling and floor effects, acceptable to good internal consistency and interrater reliability, and very good test-retest reliability. Hence, it constitutes an excellent alternative to common self-rating instruments for the assessment of functional capacities in everyday activities.

Endoscopic vaporesection of the prostate using the continuous-wave 2-microm thulium laser: outcome and demonstration of the surgical technique.

BACKGROUND: The potential of a new continuous-wave (CW) 70-W, 2.013-microm thulium-doped yttrium aluminium garnet (Tm:YAG) laser for the endoscopic treatment of benign prostatic hyperplasia (BPH) is investigated. OBJECTIVE: The simultaneous combination of vaporisation and resection of prostatic tissue in a retrograde fashion is the main characteristic of this new laser technique. We provide a DVD that shows the main steps of this procedure. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively evaluated 56 nonconsecutive patients who were treated by thulium laser vaporesection of the prostate in our institution between 2005 and 2007. SURGICAL PROCEDURE: Vaporesection of the prostate is performed by moving the fibre semicircumferentially from the verumontanum towards the bladder neck, thereby undermining tissue and cutting chips. MEASUREMENTS: Blood loss, postvoiding residual urine (PVRU), maximum flow rate (Q(max)), and the International Prostate Symptom Score (IPSS) were measured as well as prostate volume and prostate-specific antigen (PSA). The duration of the procedure, need for postoperative irrigation, duration of catheterisation, and hospital stay were recorded. RESULTS AND LIMITATIONS: The median procedure time was 60 min, postoperative irrigation was necessary in 19 out of 56 patients, and the median duration of catheterisation was 23 hr. At the day of discharge, the mean haemoglobin value decreased by 0.2mg/dl (p=0.13), the average Q(max) improved from 8.1 to 19.3 ml/s (p<0.001), and the PVRU decreased from 152 ml to 57 ml (p<0.05). The blood transfusion rate was 3.6%, and two patients needed a recatheterisation postoperatively (3.6%). After a median follow-up of 9 mo, the IPSS improved from 19.8 at baseline to 8.6 (p<0.001). Four patients had a repeat transurethral resection of the prostate (TURP) during the learning curve, but this was not necessary in any of the later patients. One patient developed a urethral stricture, and another developed a bladder neck contracture. CONCLUSIONS: The thulium laser seems to be a suitable tool for the endoscopic treatment of BPH.

[Vertigo and falls in the elderly: Part 2: Fall diagnostics, prophylaxis and therapy]. / Schwindel und Stürze im Alter: Teil 2: Sturzdiagnostik, Prophylaxe und Therapie.

In many acute or chronic vestibular diseases in old age, the risk of falling is increased. A fear of falling often develops together with further limitations to physical activity and subsequent physical and psychological consequences. Falls represent a substantial health-related risk factor. A regular balance, walking and muscle training is an effective prophylaxis. Components of the treatment of vestibular diseases in old age are counselling and encouragement (psychotherapy), treatment of the specific organic disease, specific vestibular rehabilitation and a symptomatic medication therapy. Vertigo in old age is a multifactorial process. The differential diagnosis of disorders of the equilibrium function in old age represents a challenge which can only be overcome by interdisciplinary cooperation.

[Vertigo and falls in the elderly. Part 1: epidemiology, pathophysiology, vestibular diagnostics and risk of falling]. / Schwindel und Stürze im Alter. Teil 1: Epidemiologie, Pathophysiologie, vestibuläre Diagnostik und Sturzrisiko.

Disorders of the equilibrium function in the elderly will increase in the coming years due to demographic changes in Germany. In addition to a reduction in the quality of life of affected patients, the risk of suffering from a fall increases with age. At the morphological level age-specific changes of the peripheral vestibular structures, somatosensory pathways and vision can be found, such as degenerative alterations, reduced number of cells and receptors and an accumulation of lipofuscin. Disorders of the equilibrium function in old age are individual-specific, complex procedures which develop from age-related physiological, degenerative alterations in the components of the sensomotor system which maintain equilibrium and can come into being together with vestibular and non-vestibular accompanying diseases as well as psychological factors.

Comparison of lidocaine suppositories and periprostatic nerve block during transrectal prostate biopsy.

The aim of this randomized prospective and partially double-blind study was to evaluate the efficacy of transrectal lidocaine applied as suppositories in comparison to periprostatic infiltration as methods of reducing pain during transrectal prostate biopsy. 100 patients were randomized to four groups and received either a suppository containing 60 mg of lidocaine 2 h before biopsy, a 120-mg lidocaine suppository 1 h before biopsy, a 120-mg lidocaine suppository 2 h before biopsy, or they were anaesthetized with a periprostatic infiltration of 5 ml 2% lidocaine. In all patients the same 10-core transrectal biopsy technique was performed. Pain was evaluated using a visual pain scale ranging from 0 to 10 points. The mean pain score in the 60-mg (2 h), 120-mg (1 h), and 120-mg (2 h) lidocaine suppository groups was 3.63, 3.56, and 3.58 respectively. The mean pain score of patients receiving periprostatic infiltration was 1.80. No patient showed vegetative symptoms like sweating or hypotonia. No patient had severe pain. Eight of the 9 patients with no pain were in the periprostatic injection group. Thus, all lidocaine suppositories showed a good analgesic effect although a significantly better pain reduction was achieved by periprostatic lidocaine infiltration.