Characterization of patients admitted to specialized geriatric acute care hospital units with the German version of the Standardized Evaluation and Intervention for Seniors at Risk (SEISAR) screening-instrument: a cross-sectional study.

BACKGROUND: The Standardized Evaluation and Intervention for Seniors at Risk (SEISAR) screening tool records major geriatric problems, originally applied in the emergency department. Particularly, the distinction of compensated and uncompensated problems is an interesting and new approach. Therefore, we translated the SEISAR in German language and used it to characterize patients in specialized geriatric hospital wards in Germany and to gather initial experience regarding its usability and practicability. METHODS: The tool was translated by three independent specialists in geriatric medicine and backtranslated for quality-assurance by a non-medical English native speaker. In a second step, 8 acute care geriatric hospital departments used the translated version to characterize all consecutive patients admitted over a period of one month between December 2019 and May 2020 at time of admission. RESULTS: Most of the 756 patients (78%) lived in an own apartment or house prior to hospital admission. Participants had on average 4 compensated and 6 uncompensated problems, a Barthel-Index of 40 pts. on admission with a median increase of 15 points during hospital stay, and a median length of stay of 16 days in the geriatric hospital department. CONCLUSION: SEISAR is an interesting standardized brief comprehensive geriatric assessment tool for the identification of compensated and uncompensated health problems in older persons. The data of this study highlights the number, variability, and complexity of geriatric problems in patients treated in specialized acute care geriatric hospital wards in Germany. TRIAL REGISTRATION: German Clinical trial register (DRKS-ID: DRKS00031354 on 27.02.2023).

[Long-term care facilities during the COVID-19 pandemic : Considerations on the way back to normality]. / Langzeitpflegeeinrichtungen in der COVID-19-Pandemie : Überlegungen auf dem Weg zurück in die Normalität.

Long-term care facilities (LTCF) were and are particularly affected by the COVID-19 pandemic. The dimensions of the outbreaks and the high mortality among residents led to massive restrictions in LTCFs, especially in the area of social contacts and activities but also in areas of medical care. With the start of vaccinations and the improved testing options, the situation has now changed and existing restrictions must be evaluated to determine whether they are still appropriate. In an interprofessional and interdisciplinary group of experts, considerations have been formulated on how a way back to normality could look like in LTCFs.

Reliability of the blood pressure response during performance of bedside Valsalva maneuver and association with NT-pBNP levels.

BACKGROUND: Heart failure (HF) is common in older people. The diagnosis of HF, however, is difficult in older subjects, especially in settings without direct access to further diagnostics. The type of blood pressure response during the performance of a Valsalva maneuver has been suggested as an easily applicable bedside test to detect HF; however, the reliability of this maneuver and the association with HF is unknown in geriatric patients. METHODS: This study included 89 patients admitted for geriatric rehabilitation. Systolic blood pressure was taken while the patient performed a Valsalva maneuver. The systolic blood pressure response was classified as sinusoidal (type A), absent overshoot (type B) or square pattern (type C). To test interrater reliability systolic blood pressure response was evaluated independently by two investigators. The procedure was repeated after 1h to estimate test-retest reliability. Both investigators were blinded to the results of the other. Interrater reliability and test-retest reliability were calculated using Cohen's kappa. Blood samples for N­terminal pro brain natriuretic peptide (NT-pBNP) were obtained on the morning the Valsalva maneuver was performed. RESULTS: Blood pressure response was sinusoidal in 37 (42%), showed an absent overshoot in 17 (19%) and had a square wave pattern in 34 (38%) patients. Cohen's kappa was 0.911 (95% CI 0.837-0.985) for interrater reliability and 0.929 (95% CI 0. 0.862-0.996) for test-retest reliability. The interrater and test-retest agreement were 94% and 96%, respectively. The mean NT-pBNP plasma levels and the interquartile ranges (IQR) in subjects with types A, B and C blood pressure response pattern were 213 (153-324) pg/ml, 805 (622-1332) pg/ml and 3964 (2595-5906) pg/ml, respectively (p < 0.001). CONCLUSION: The blood pressure response during a Valsalva maneuver shows an excellent reliability in older subjects. The type of response is associated with the NT-pBNP plasma level.

[Sleep and sleep disorders in the elderly: Part 3: Restless legs syndrome]. / Schlaf und Schlafstörungen beim alten Menschen: Teil 3: Restless-legs-Syndrom.

Restless legs syndrome (RLS) is a commonly occurring condition with a prevalence of approximately 10%. Women are more often affected than men. There is a primary and a secondary form. Secondary RLS is triggered by iron deficiency, severe renal insufficiency and many drugs and medications. The treatment for RLS is always symptomatic. In addition to treating associated diseases, dopaminergic therapy is paramount. Pharmacotherapy encompasses levodopa (L-dopa) and dopamine agonists, such as pramipexole, ropinirole and rotigotine. A serious complication of dopaminergic therapy is the so-called augmentation. In the case of insufficient efficacy, severe discomfort or augmentation, oxycodone/naloxone is now approved for the treatment of RLS.

[Sleep and sleep disorders in the elderly. Part 2: therapy]. / Schlaf und Schlafstörungen beim alten Menschen. Teil 2: Therapie.

Sleep disorders need to be treated if they affect the quality of life, lead to functional problems in daily life or unfavorably affect self-sufficiency. The large number of sleep disorders is reflected in the number of different and varied available therapeutic procedures. The basic therapeutic procedure for any sleep disorder is the use of sleep hygiene. Sleeplessness (insomnia) is most effectively treated through behavioral therapy, with stimulus control and sleep restriction as the most effective measures, whereas pharmacotherapy is considerably less effective and has side effects. Sleep-disordered breathing is also the most common cause of hypersomnia in the elderly and is most effectively treated by nocturnal positive pressure breathing.

[Sleep and sleep disorders in the elderly: Part 1: epidemiology and diagnostics]. / Schlaf und Schlafstörungen beim alten Menschen: Teil 1: Epidemiologie und Diagnostik.

Restorative sleep is an important factor for well-being, performance and quality of life. The basic diagnostic procedure of a sleep disorder is to take a comprehensive sleep history. Sleep disorders can and must be distinguished from the physiological changes of sleep in the elderly. Insomnia (difficulty in sleeping), daytime sleepiness (hypersomnia), sleep-related breathing disorders (SRBD) and movement disorders during sleep are also common in the elderly. They must be detected because they are treatable and can dominate the clinical picture of geriatric syndromes. Nursing home residents and dementia patients are in particular need of attention as their sleep is often adversely affected by the living environment and the daily institutional routine.

Treatment of chronic obstructive pulmonary disease in hospitalized geriatric patients.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is frequent in older subjects due to deterioration of pulmonary function and lifelong exposure to risk factors. Furthermore, COPD is often underreported because of the gradual onset of symptoms and reduced perception of symptoms in the elderly. There is thus a risk of undertreatment of COPD in older subjects. METHODS: We retrospectively analyzed dossiers of 229 hospitalized geriatric patients with COPD, complete assessment datasets and successful lung function tests. RESULTS: The sample comprised 78 men (38 %; mean age 77 ± 7 years) and 151 women (66 %; mean age 81 ± 6 years). The number of untreated patients decreased from 68 (28 %) at admission to 35 (14 %) at discharge (p < 0.01). Absence of treatment was associated with severity of disease: mild COPD was less likely to be treated. During the hospital stay, the prescription of metered dose inhalers (MDIs) decreased and the prescription of nebulizers increased, most likely due to the coordination problems associated with using inhalers. CONCLUSION: Undertreatment of COPD is frequent among hospitalized geriatric patients. There is a need for adaption of current guidelines to the needs of older patients with frailty or cognitive impairment.

Impact of daytime sleepiness on rehabilitation outcome in the elderly.

Daytime sleepiness (DS) is associated with poor health, impaired physical functioning, as well as somatic and psychiatric morbidity. The impact of DS on functional outcome in the elderly is unknown. We investigated whether observed daytime sleepiness in geriatric patients with moderate to severe functional impairment was associated with functional clinical outcomes. We addressed the issue by determining the impact of observed daytime sleepiness, by means of the Essener Questionnaire of Age and Sleepiness (EQAS), on improvement in functional status - measured by the Barthel ADL Index - among disabled geriatric in-patients. We included 129 patients, 28 (22%) were male and 101 (78%) were female. Sleepiness according to EQAS scale was absent in 27 (21%) patients, mild in 71 (55%) patients and moderate to severe in 31 (24%) patients. The three patient groups did not differ in the Barthel ADL Index (BI) on admission or co-morbid conditions. Geriatric treatment was comparable across groups. Improvement in the BI of at least 1 standard deviation (SD) occurred in 23/27 (85%) of subjects without sleepiness, in 53/71 (75%) of subjects with mild to moderate sleepiness and in 15/31 (44%) of subject with severe sleepiness (p < 0.01). BI increased at least 2 SD in 20/27 (74%), 38/71 (54%) and 11/31 (35%) individuals, respectively (p < 0.02). We conclude that the daytime sleepiness predicts a poorer functional recovery rate in older patients during geriatric in-hospital rehabilitation. Furthermore, we found a significant association and a dose response relationship between severity of daytime sleepiness and improvement in Barthel ADL Index.

Validation of the Essener Questionnaire of Age and Sleepiness in the elderly using pupillometry.

In the elderly population, daytime sleepiness (DS) is a burden that affects quality of life, cognitive and physical functioning as well as health status and morbidity. The measurement of DS in older subjects continues to be a challenge, as there are only few elderly-specific assessment tools available. Therefore, we compared the newly developed Essener Questionnaire of Age and Sleepiness (EQAS) with pupillography, a physiological measure of sleepiness. The aim was to identify EQAS cut-off values for increased daytime sleepiness. For the validation study, we determined EQAS scores and the pupillary unrest index (PUI) of the pupillographic sleepiness test (PST) in 88 geriatric in-patients. We also collected data on age, gender, co-morbidities, and geriatric assessment in these subjects. Of all included patients 37 (42%) completed the PST. Fourteen (16%) subjects refused to participate and 37 (42%) subjects could not complete 11 min required for a valid PUI. Subjects with complete and incomplete pupillometry did not differ in basic assessment parameters of health status or cognitive functioning. EQAS scores correlated significantly with PUI values (r = 0.70; p < 0.001) demonstrating a dose-response relationship. Based on ROC analysis, an EQAS score above 3 was optimal to distinguished sleepy from non-sleepy participants with sensitivity of 67%, specificity of 93% and positive and negative predictive values of 75% and 90%, respectively. In conclusion, the high negative and positive predictive values of the EQAS indicate that this instrument is a useful and valid assessment tool for daytime sleepiness in the elderly. The easy administration of this observational instrument favors its adoption in geriatric medicine.

Dementia among older in-hospital patients with obstructive airway disease: frequency and consequences.

BACKGROUND: Dementia may influence as a co-morbid condition the management of chronic obstructive airway disease. However, the frequency and the consequences of dementia in older people with chronic obstructive airway disease are largely unknown. PATIENTS AND METHODS: The frequency and the severity of dementia in geriatric in-hospital patients and its impact on feasibility of lung function testing and drug treatment provided were determined. RESULTS: Out of a total of 1,424 patients with obstructive airway disease, 433 (30%) suffered from mild and 307 (22%) suffered from moderate to severe dementia. The frequency of any treatment for obstructive airway disease on admission decreased from 58% in subjects without dementia to 51% of those with mild and to 36% of those with moderate to severe dementia (p<0.01). The feasibility of performing lung function testing also decreased with increasing prevalence of dementia from 86% to 66% and 43%, respectively (p<0.001). CONCLUSION: Dementia is a frequent finding in older in-hospital patients with obstructive airway disease. The majority of subjects with dementia were not able to perform lung function testing. Furthermore, the risk of undertreatment for chronic obstructive airway disease increased. Future guidelines for management of obstructive airway disease must also take into account the special needs and skills of older subjects with dementia.

Handgrip strength measurement as a predictor for successful dry powder inhaler treatment: application in older individuals with COPD.

BACKGROUND: More than 10% of elderly people suffer from chronic obstructive pulmonary disease (COPD). Drug treatment for COPD involves inhalants. Dry powder inhalers (DPIs) have proven easiest for the elderly to use. Their effectiveness is dependent, however, on the inspiratory flow which can be generated, and it is unclear which geriatric assessment parameter permits inspiratory flow to be assessed. METHODS: In a randomly generated group of geriatric hospital patients, manual strength was measured as a complement to basic geriatric assessment and inspiratory flow assessed using a Turbohaler trainer. RESULTS: A total of 87 (27%) men (mean age 81 ± 7 years) and 231 (73%) women (mean age 82 ± 8 years) were included in the study. The threshold value of 40 l/min for minimum inspiratory flow was achieved by 194 (61%) of the patients. Manual strength was the only assessment parameter to correlate with the minimum inspiratory flow achieved. ROC analysis produced a threshold value for manual strength of 10 kg. The sensitivity and specificity for this threshold value were 70% each, while the positive and negative predictive values were 79% and 84%, respectively. CONCLUSION: A threshold value of 10 kg for manual strength enables the inspiratory flow achievable by elderly patients to be predicted satisfactorily. This is the only parameter which correlates sufficiently with inspiratory flow. Manual strength should be measured in all geriatric patients with COPD and should be taken into account when deciding whether or not to initiate differential treatment.

[Assessment of drug treatment in geriatrics with the new FORTA criteria]. / Bewertung von Medikamenten in der Geriatrie mit der neuen FORTA-Klassifikation.

BACKGROUND: Multimorbidity in the elderly often leads to inappropriate and harmful polypharmacy. Various approaches have been used to prioritize components of drug treatment, especially as on negative lists like the Beers list. A new approach is the FORTA assessments system ( Fit f OR The Aged) in which drugs are graded as positive (A, should be given), intermediate (B or C), and negative (D should not be given). METHODS: In this pilot study of 46 patients in a geriatric ward medication was assessed on admission and at discharge, using the FORTA criteria. All changes in the number of prescribed drugs, the distribution of FORTA criteria, and the number of drug interactions were recorded. RESULTS: The use of FORTA resulted in a decrease in the total number of prescirbed drugs from 7.3 ± 2,9 to 6.7 ± 2,3 (p = 0.06), and an increase in positively assessed drugs (A / B) from 59 ± 20 to 77 ± 38 % (p < 0.01), as well as a decrease in negatively assessed drugs (D) from 7 ± 12 to 5 ± 9 % (p = 0.06). The number of drugs assessed as intermediate (C) did not change significantly. Under-treatment decreased from 65 to 39 % (p < 0.01), over-treatment from 65 % to 20 % (p < 0.01). The number of drug interactions decreased from 79 to 54 (p < 0.01). CONCLUSION: This uncontrolled pilot study indicates that the FORTA criteria can be used in day-to-day clinical care: it describes the quality of changes in drug treatment in a geriatric ward in a plausible way. This study has provided basic uncontrolled data which should be validated in controlled studies comparing the quality of treatment with or without the use of the FORTA criteria. (DKRS-ID: DRKS00000531).

The terminal phase of life as a team-based clinical global judgment: prevalence and associations in an acute geriatric unit.

BACKGROUND: In most elderly people, the final-terminal-phase of life is characterized by permanent dependency and a complete inability to perform activities of daily living. Treatment targets usually switch from rehabilitation to palliation. However, the prevalence of the clinical judgment "last phase of life" and its association with in-hospital death is unknown in geriatric patients. PATIENTS AND METHODS: We retrospectively analyzed GEMIDAS data from two geriatric units. Patients without cancer and an in-hospital stay of at least 1 week were included in our study. Prevalence of the terminal phase of life was clinically assessed according to the proposals made by M. Gillick. This clinical judgment was pronounced by the geriatric team after a stay in the hospital of at least 1 week. The clinical judgment took into account all available assessment parameters, as well as the impact of a geriatric treatment trial. In addition, the association between the clinical judgment and the risk of in-hospital mortality was analyzed. RESULTS: Records from 2,433 (56%) patients in hospital A and from 1,912 (44%) patients in hospital B were analyzed. The frequency of a terminal phase of life was 30% and 9% (p<0.01), respectively. The frequency depended on the manner of admission to the hospital. In both hospitals, mortality was significantly higher in terminal patients (27% and 37%) than in other patients (0-8% and 0-6%). In both hospitals, the risk of in-hospital mortality was significantly associated with the clinical judgment (OR 3.1 and 2.7), heart failure (OR 2.2 and 2.1), and dementia (OR 2.0 and 1.8). Age, residency in a nursing home, and the Barthel Index on admission were all without relevant impact. CONCLUSION: The frequency of the clinical construct "terminal phase of life" varies in geriatric units between 9% and 30%. This clinical construct is significantly associated with increased in-hospital mortality. Therefore, this construct possesses external validity. Further studies are needed in order to assess the significance of such a clinical judgment, the associations with clinical burdens of symptoms, and the supply structure required to cover the needs of patients and their families.

Acceptance of NCPAP in a sample of patients admitted for geriatric rehabilitation.

OBJECTIVE: Sleep apnea syndrome (SAS) is common in older people. Nasal continuous airway pressure (NCPAP) therapy is the treatment of choice for sleep apnea, but is not always accepted by patients. The rate of successful initiation of NCPAP is unknown in geriatric patients. METHODS: All patients admitted for geriatric rehabilitation were considered for sleep studies. Sleep apnea was assessed using an Edentrace (Nellcor, Hayward, CA) multi-channel recording system. SAS was defined as an apnea-hypopnea-index (AHI) of more than five events per hour plus excessive daytime sleepiness, or an AHI of more than fifteen events per hour regardless of reported sleepiness. Disability was assessed using the Barthel Index of Activities of Daily Living. RESULTS: Two hundred sixty nine of 322 consecutive patients (84%) had adequate sleep studies and gave informed consent. SAS was found in 169 subjects (68%). There was no gender difference in the prevalence of SAS. Six subjects (4%) accepted NCPAP therapy. Individuals who accepted NCPAP were younger and less disabled (p<0.03). Multiple logistic regression analysis revealed disability as the only significant factor predicting NCPAP acceptance. CONCLUSION: NCPAP should not be withheld in the elderly. However, initiation of treatment for SAS remains to be a great challenge in those patients. Geriatric assessment procedures may help better manage older subjects with sleep apnea syndrome.

Feasibility of the Epworth Sleepiness Scale in a sample of geriatric in-hospital patients.

Excessive daytime sleepiness (EDS) is a major health concern in geriatric patients. EDS affects quality of life, daytime function, and mortality. The Epworth Sleepiness Scale (ESS) is a standard tool for the assessment daytime sleepiness, but the feasibility of the ESS has never been investigated in elderly subjects. We applied the ESS to a random sample of geriatric in-hospital patients. The aim of the study was to reveal the frequency and the risk factors for processing failure of the ESS in geriatric patients. 458 patients with a mean age of 82+/-8 years were included. One hundred sixty six (36%) completed the ESS, 118 (28%) patients had omissions of items, and 174 (38%) patients were unable to respond to any item. Completion of the ESS correlated significantly with age, disability, dementia, impairment of vision, and hearing. Omitted items were related to mobility and activities outside the house. Logistic regression analysis with completed ESS as a dependent variable revealed that dementia, disability, heart failure, and COPD were independent and significant risk factors for processing failure. The majority of patients of a geriatric unit are unable to complete the ESS. Since EDS is a frequent finding with a negative impact on health, the development of a reliable and valid tool for the assessment of EDS in elderly subjects is needed.

Influence of type of treatment for sleep apnea on activities of daily living in a sample of elderly patients with severe sleep apnea.

Sleep disordered breathing (SDB) is a frequent finding in the elderly. SDB is related to morbidity, mortality, quality of life, disability, and cognitive impairment. Treatment of choice for SDB is nasal positive airway pressure breathing (nCPAP). The impact of treatment for SDB on activities of daily living (ADLs) is unclear. We therefore investigated the relationship between SDB and ADLs in a sample of elderly in-hospital patients with severe SDB defined as a oxygen desaturation index of 30 events per hour. All patients eligible were assigned to nCPAP therapy. Patients with refusal of nCPAP were offered nocturnal oxygen supply via nasal prongs. The Barthel-index (BI) at admission and discharge was used to measure ADLs. Two hundred patients with a mean age of 81+/-7 years were included. 22 (11%) patients accepted nCPAP therapy, 42 (21%) patients accepted oxygen therapy and 136 (68%) patients refused both treatment options. The subgroups did not differ significantly in BI at admission and length of stay in hospital. BI increased from 42+/-28 to 49+/-30 in patients with refusal of any treatment, from 39+/-23 to 61+/-20 in patients with oxygen therapy and from 48+/-35 to 72+/-28 in patients with nCPAP therapy. The BI at discharge differed significantly between all three patients groups (p< 0.03). Logistic regression analysis revealed that Barthel Index at admission and treatment with nCPAP or treatment with oxygen were independently associated with a gain in BI of at least 30 points. Age, dementia or length of in-hospital stay showed no association with gain in BI. This is the first study that shows an impact of treatment for severe SDB on ADLs in elderly patients. Furthermore, treatment with nCPAP and oxygen supply nearly had the same impact on ADLs. Since the higher rate of acceptance of oxygen therapy and the important impact of oxygen supply on BI, administration of oxygen seems to be a rational alternative in elderly subjects with severe sleep apnea and refusal of nCPAP.