[Feasibility, Practicability, and Acceptance of Outpatient Psychotherapy for Home-living Older Adults with Depression in Need of Care in Germany]. / Implementierbarkeit, Praktikabilität und Akzeptanz ambulanter Psychotherapie für zuhause lebende ältere Menschen mit Depression und Pflegebedarf ­ Ergebnisse des Innovationsfondsprojekts PSY-CARE.

OBJECTIVE: This study investigates the feasibility of outpatient psychotherapeutic depression-treatment for home living older adults in need of care within the German health-care system. METHODS: PSY-CARE is a manual based, pragmatic randomized controlled trial investigating the effects of short-term behavioural therapy for home living adults aged 60+ with clinical depression and need of care. RESULTS AND CONCLUSION: Our results suggest that health policy should implement home-visits, interprofessional cooperation and involvement of relatives as standard outpatient psychotherapy elements. Specialised geropsychological training for psychotherapists is needed.

Concordance of self- and informant-rated depressive symptoms in nursing home residents with Dementia: cross-sectional findings.

BACKGROUND: Depression is highly prevalent in nursing home residents living with moderate to severe dementia. However, assessing depressive symptoms in residents with dementia can be challenging and may vary by rater perspective. We aimed to investigate the concordance of, and factors associated with self- and informant-rated depressive symptoms in nursing home residents with dementia. METHODS: Cross-sectional data was collected from N = 162 nursing home residents with dementia (age: 53-100; 74% women). Self-ratings were assessed with the Geriatric Depression Scale, while the depression and anxiety items of the Neuropsychiatric Inventory were used for informant-ratings. Cohen's Kappa was calculated to determine the concordance of both measures and of each with antidepressant medication. Multivariate associations with sociodemographic variables, self- and informant-rated quality of life, dementia stage, neuropsychiatric symptoms, functional status and antidepressant medication were analysed with linear mixed models and generalized estimating equations. RESULTS: Concordance between self- and single item informant-rated depressive symptoms was minimal (Cohen's Kappa = .22, p = .02). No concordance was found for self-reported depressive symptoms and the combined informant-rated depression-anxiety score. Self-reported depression was negatively associated with self-rated quality of life (ß = -.32; 95%CI: -.45 to -.19, p < .001), informant-rated quality of life (ß = -.25; 95%CI: -.43 to -.07, p = .005) and functional status (ß = -.16; 95%CI: -.32 to -.01, p = .04), whilst single item informant-rated depression revealed negative associations with informant-rated quality of life (ß = -.32; 95%CI: -.52 to -.13, p = .001) and dementia stage (ß = -.31; 95%CI: -.52 to -.10, p = .004). The combined informant-rated depression-anxiety score showed negative associations with self-rated quality of life (ß = -.12; 95%CI: -.22 to -.03, p = .01) and dementia stage (ß = -.37; 95%CI: -.67 to -.07, p = .02) and a positive association with neuropsychiatric symptoms (ß = .30; 95%CI: .10 to .51, p = .004). No concordance was found with antidepressant medication. CONCLUSIONS: In line with our expectations, low agreement and unique association patterns were found for both measures. These findings indicate that both instruments address different aspects of depression und underline the need for comprehensive approaches when it comes to detecting signs of clinically relevant depressive symptoms in dementia. TRIAL REGISTRATION: The trial was registered with the ISRCTN registry (Trial registration number: ISRCTN98947160 ).

Evaluation of Recruitment Strategies for Home-Living Vulnerable Older Adults With Depression: Findings From a Randomized Controlled Psychotherapy Trial.

OBJECTIVE: Vulnerable older adults, such as physically impaired or care-dependent individuals, are vastly underrepresented in psychotherapy research. Improving their inclusion in randomized controlled trials is necessary to determine the effectiveness of psychotherapy in this population. This study is the first to systematically evaluate strategies to recruit home-living vulnerable older adults with clinically significant depression into a large randomized controlled psychotherapy trial. Potential participants were approached directly (self-referral) or via cooperation with gatekeepers (gatekeeper-referral). METHODS: Successful recruitment strategies and the person initiating the first contact with the study team were recorded. Recruitment strategies were compared with respect to the number of inquiries and inclusion rates, study personnel's time investment, and participant characteristics (sociodemographics, functional and cognitive status, depression and anxiety scores). RESULTS: Most of the N = 197 participants were included via gatekeeper-referral (80.5%, 95% confidence interval = [74.9, 86.1]), but time investment for gatekeeper-referrals was five times higher than for self-referral by media reports. Clinical psychologists and medical practitioners referred the largest proportion of participants (32.3% each) and referral by medical practitioners led to highest inclusion rates (55.6%; χ²(3) = 8.964, p <0.05). Most participants were referred from a hospital setting (50.3%), whereas referral numbers by medical practices were low (15.9%). Participants who initiated the first contact themselves had higher inclusion rates and were less functionally impaired. CONCLUSION: Including home-living vulnerable older adults into psychotherapy trials requires simultaneous implementation of diverse recruitment strategies. Medical practitioners and psychologists, especially in hospitals, are the most effective recruitment strategy, but self-referral via media is most cost-efficient in terms of time investment.

Diabetes duration and the risk of dementia: a cohort study based on German health claims data.

OBJECTIVE: Diabetes is a risk factor for dementia but little is known about the impact of diabetes duration on the risk of dementia. We investigated the effect of type 2 diabetes duration on the risk of dementia. DESIGN: Prospective cohort study using health claims data representative for the older German population. The data contain information about diagnoses and medical prescriptions from the in- and outpatient sector. METHODS: We performed piecewise exponential models with a linear and a quadratic term for time since first type 2 diabetes diagnosis to predict the dementia risk in a sample of 13,761 subjects (2,558 dementia cases) older than 65 years. We controlled for severity of diabetes using the Adopted Diabetes Complications Severity Index. RESULTS: We found a U-shaped dementia risk over time. After type 2 diabetes diagnosis the dementia risk decreased (26% after 1 year) and reached a minimum at 4.75 years, followed by an increase through the end of follow-up. The pattern was consistent over different treatment groups, with the strongest U-shape for insulin treatment and for those with diabetes complications at the time of diabetes diagnosis. CONCLUSIONS: We identified a non-linear association of type 2 diabetes duration and the risk of dementia. Physicians should closely monitor cognitive function in diabetic patients beyond the first few years after diagnosis, because the later increase in dementia occurred in all treatment groups.

Current state of research on psychotherapy for home-living vulnerable older adults with depression.

Older home-living vulnerable adults often suffer from chronic conditions accompanied by restrictions in mobility, social participation and reduced independence. Among this rapidly growing population depression is a common and serious health problem; however, there are shortcomings in the diagnosis of depression and provision of psychotherapy. Despite growing evidence in treating depression among the group of nursing home residents or the "young-old", there is a research gap regarding needs-oriented healthcare strategies for very old, frail or care-dependent older adults living at home. The present article provides an overview of different outpatient psychotherapeutic treatment approaches for vulnerable older adults with depression, in particular adaptations tailored to those who are homebound or in need of care. Based on the current state of research, this article derives recommendations for psychotherapy in this special setting to consider the physical and psychosocial resources of this patient group. Furthermore, healthcare strategies for embedding psychotherapy in collaborative, telehealth or home-delivered healthcare services are described and their applicability as psychosocial support for older adults during the coronavirus disease 2019 (COVID-19) pandemic is discussed. Psychotherapy is an efficacious treatment for depression in home-living vulnerable older adults. Further implementing telehealth or home delivered settings, individually tailored psychotherapeutic approaches as well as collaborative and stepped care approaches can increase utilization and medical supply of this patient group. More research and innovative programs are needed to improve access to and provision of psychotherapeutic care as well as their social inclusion.

Outpatient psychotherapy for home-living vulnerable older adults with depression: study protocol of the PSY-CARE trial.

BACKGROUND: There is a need to improve psychotherapeutic approaches to treatment for vulnerable older adults with depression in terms of both clinical practice and health care supply. Against this background, PSY-CARE is testing the feasibility and effectiveness of outpatient psychotherapy for home-living older adults in need of care with depression in Berlin, Germany, and neighboring suburban areas. METHODS: In a two-arm single-center pragmatic randomized controlled trial (RCT), manual-guided outpatient psychotherapy will be compared to brief psychosocial counseling. The study population will be compromised of older adults with clinically significant depressive symptoms who have a long-term care grade, as assessed by the German compulsory state nursing care insurance. In the intervention group, individual cognitive-behavioral psychotherapy tailored to the specific needs of this population will be offered by residential psychotherapists as part of the regular healthcare service. In the active control group, participants will receive individual psychosocial telephone counselling and a self-help guide. The planned sample size is N = 130 (n = 65 participants per group). The reduction of depressive symptoms (primary outcome) as well as the maintaining of activities of daily living, quality of life, and functioning will be assessed with questionnaires provided at baseline, after the end of the intervention and after three months. Feasibility and process evaluation will be conducted qualitatively based on documentation and interviews with psychotherapists, gatekeepers and the participants. DISCUSSION: PSY-CARE investigates the potentials and limitations of providing outpatient psychotherapeutic treatment meeting the demands of vulnerable home-living older adults with depression under the real conditions of the health care system. The study will provide practical implications to improve access to and quality of outpatient psychotherapy for this poorly supplied population. TRIAL REGISTRATION: The trial is registered at ISRCTN55646265 ; February 15, 2019.

Sexual activity, sexual thoughts, and intimacy among older adults: Links with physical health and psychosocial resources for successful aging.

Research on close relationships in later life has received increased attention over the past decade. However, little is known about sexuality and intimacy in old age. Using cross-sectional data from the Berlin Aging Study II (BASE-II; Mage = 68 years, SD = 3.68; 50% women; N = 1,514), we examine age differences in behavioral (sexual activity), cognitive (sexual thoughts), and emotional (intimacy) facets of sexuality and investigate associations with physical health and psychosocial resources for successful aging. Older age was associated with less sexual activity and fewer sexual thoughts, but not with differences in intimacy. Relative to a reference sample of 22- to 36-year-olds within BASE-II (N = 475), the average older adult reported considerably fewer sexual activity and thoughts (ds > .60), but only slightly lower intimacy (d = .20). Substantial heterogeneity existed among older adults, with almost one third of the 60- to 82-year-olds reporting more sexual activity and thoughts than the average younger adult. Examining correlates of sexuality among older adults revealed that, covarying for diagnosed illnesses and performance-based grip strength, psychosocial factors (e.g., partnered, relationship satisfaction) accounted for considerable shares of variance in sexual activity and intimacy, whereas age and gender explained more of the variance in sexual thoughts. Some psychosocial factors exhibited similar-sized associations with all sexuality facets, whereas other factors operated in more facet-specific ways. To illustrate, participants reporting more loneliness also reported less sexual activity and less intimacy, but not fewer sexual thoughts. We discuss implications of our findings for theories of successful aging. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Different treatment forms of type II diabetes and the risk of dementia in German health claims data.

AIMS: The association between type II diabetes (T2D) and increased all-cause dementia risk is well established. However, to date, there is no definite proof that a specific therapy for diabetes can halt a progress of cognitive decline. Therefore, we analyzed a large longitudinal random sample of German health claims data to focus on associations between T2D and dementia and to elucidate the role of different treatment forms of T2D on the risk for dementia. METHODS: We used a longitudinal random sample (n = 250,000) of claims data of the largest public sickness fund in Germany, the Allgemeine Ortskrankenkasse (AOK). Dementia was defined as ICD-10 codes G31.0, G31.82, G23.1, F00, F01, F02, F03, and F05, and T2D was defined as E11-E14. We performed Cox proportional hazard models to explore the transition into dementia and to calculate the relative risk of dementia dependent on T2D and different T2D treatment forms. RESULTS: All models were adjusted for sex, age, and each patient's history of depression, renal insufficiency, and cardiovascular comorbidities. Non-pharmacologic-treated diabetics showed a 23% increased dementia risk (p < 0.001) and oral ADM-treated diabetics showed a 16% increased risk (p < 0.001). Insulin-dependent diabetics is still the highest dementia risk (40%; p < 0.001) and obesity additionally attenuated this risk (75%; p < 0.001) increased risk. CONCLUSIONS: We found that diabetes is an independent risk factor for all-cause dementia. An increased risk for dementia in insulin-dependent and obese subjects with diabetes was evident. Longitudinal studies on the effect of different forms of therapy and weight reduction are needed to verify the results of this study.

Physical activity and cohabitation status moderate the link between diabetes mellitus and cognitive performance in a community-dwelling elderly population in Germany.

AIMS/HYPOTHESIS: The increasing number of people with dementia and cognitive impairments makes it essential to detect and prevent modifiable risk factors of dementia. This study focuses on type 2 diabetes mellitus, especially on undiagnosed cases and their increased risk of cognitive impairment. Furthermore, the potential of physical activity and social integration to moderate the relation between diabetes and cognitive impairment is assessed. METHODS: We used cross-sectional data from 1299 participants of the Berlin Aging Study II (BASE-II) aged between 60 to 84 years and performed logistic regression models to analyze the association of diabetes status, physical activity, and cohabitation status with poor cognitive performance. Cognitive performance was measured with the Consortium to Establish a Registry for Alzheimer's Disease (CERAD)-Plus test battery. RESULTS: Undiagnosed diabetes (odds ratio (OR) = 2.12, p = 0.031), physical inactivity (OR = 1.43, p = 0.008) and non-cohabiting (OR = 1.58, p = 0.002) were associated with an increased likelihood of poor cognitive performance. The highest odds were observed in participants who suffered from undiagnosed or insulin-dependent diabetes and, in addition, were inactive (undiagnosed diabetes: OR = 3.44, p = 0.003; insulin-dependent diabetes: OR = 6.19, p = 0.019) or lived alone (undiagnosed diabetes: OR = 4.46, p = 0.006; insulin-dependent diabetes: OR = 6.46 p = 0.052). Physical activity and cohabiting appeared to be beneficial. CONCLUSIONS/INTERPRETATION: Physical activity and cohabitation status moderate the link between diabetes mellitus and cognitive performance. Special attention should be paid to undiagnosed and insulin-dependent diabetes cases, which have a particularly high risk of poor cognitive performance.

The inflammatory markers CRP, IL-6, and IL-10 are associated with cognitive function--data from the Berlin Aging Study II.

Inflammation may be an underlying mechanism in cognitive decline. The present study investigated the relationship between cognitive function and the inflammatory markers C-reactive protein (CRP), interleukin (IL)-6, and IL-10 in a nonclinical sample of elderly adults. Serum levels of CRP, IL-6, and IL-10 were measured in n = 1312 elderly adults (60-85 years, 50.5% females) who underwent comprehensive neuropsychological testing. Multiple linear regression analysis was conducted and adjusted for various demographic and clinical factors. Levels of IL-6, IL-10, and CRP were negatively associated with a composite score of executive function and processing speed, whereas the IL-6 to IL-10 ratio was not predictive for executive function and processing speed. No associations were found between inflammatory markers and verbal episodic memory. These findings suggest a relationship between higher proinflammatory and anti-inflammatory activation of the innate immune system and executive function within the normal range. Further research is needed to examine the relevance of an inflammatory pathway as a potential therapeutic target.

MicroRNA-138 is a potential regulator of memory performance in humans.

Genetic factors underlie a substantial proportion of individual differences in cognitive functions in humans, including processes related to episodic and working memory. While genetic association studies have proposed several candidate "memory genes," these currently explain only a minor fraction of the phenotypic variance. Here, we performed genome-wide screening on 13 episodic and working memory phenotypes in 1318 participants of the Berlin Aging Study II aged 60 years or older. The analyses highlight a number of novel single nucleotide polymorphisms (SNPs) associated with memory performance, including one located in a putative regulatory region of microRNA (miRNA) hsa-mir-138-5p (rs9882688, P-value = 7.8 × 10(-9)). Expression quantitative trait locus analyses on next-generation RNA-sequencing data revealed that rs9882688 genotypes show a significant correlation with the expression levels of this miRNA in 309 human lymphoblastoid cell lines (P-value = 5 × 10(-4)). In silico modeling of other top-ranking GWAS signals identified an additional memory-associated SNP in the 3' untranslated region (3' UTR) of DCP1B, a gene encoding a core component of the mRNA decapping complex in humans, predicted to interfere with hsa-mir-138-5p binding. This prediction was confirmed in vitro by luciferase assays showing differential binding of hsa-mir-138-5p to 3' UTR reporter constructs in two human cell lines (HEK293: P-value = 0.0470; SH-SY5Y: P-value = 0.0866). Finally, expression profiling of hsa-mir-138-5p and DCP1B mRNA in human post-mortem brain tissue revealed that both molecules are expressed simultaneously in frontal cortex and hippocampus, suggesting that the proposed interaction between hsa-mir-138-5p and DCP1B may also take place in vivo. In summary, by combining unbiased genome-wide screening with extensive in silico modeling, in vitro functional assays, and gene expression profiling, our study identified miRNA-138 as a potential molecular regulator of human memory function.

Acceptance of and attitudes towards Alzheimer's disease screening in elderly German adults.

BACKGROUND: Considering the discussion on implementing routine dementia screening in Germany, the objective of the current study was to validate the German version of the Perceptions Regarding Investigational Screening for Memory in Primary Care (PRISM-PC) questionnaire and to determine the acceptance of Alzheimer's disease screening in elderly German adults. METHODS: The German version of the PRISM-PC was administered to a subsample of participants who attended the Berlin Aging Study II (n = 506). The questionnaire was validated by exploratory as well as confirmatory factor analysis. RESULTS: Regarding acceptance of Alzheimer's disease screening (Section B) a single factor structure fitted best. In terms of attitudes regarding Alzheimer's disease (Section D), a hierarchical factor structure was modeled with the higher-order factor "Harms" covering the domains "Family Burden," "Dependence," "Emotional Suffering," "Stigma," and "Medical Care" on the one hand and the domain "Future Planning" on the other hand. Internal consistency of the different scales reached from α = 0.67 to α = 0.94. Overall, 71.2% of the participants indicated that they wanted to be screened for Alzheimer's disease on a regular basis. CONCLUSIONS: This study suggests that acceptance can reliably be assessed with the section "Acceptance of Alzheimer's disease screenings" of the German PRISM-PC questionnaire. Furthermore, the majority of elderly German adults would like to be screened for Alzheimer's disease regularly, which might be an effective starting point in order to implement routine dementia screenings. As the sample is a convenience sample of (relatively) healthy older adults, generalizability of these results is limited.