Hemophilus influenza infection of an implantable insulin-pump pocket.

OBJECTIVE: To increase awareness of adverse events associated with the use of implantable insulin pumps. RESEARCH DESIGN AND METHODS: A descriptive case report of a pump implant infection. RESULTS: This is a case report of one implanted insulin pump-pocket infection among a series of 15 patients. After exposure to a child with a respiratory infection on PID 30, V.L.C. (the patient) developed a fulminant pump-pocket infection. H. influenza was recovered from it. Despite aggressive antibiotic therapy, the infection could not be controlled. Insulin delivery ceased, and the pump was explanted. The pump-pocket infection rapidly resolved with pump removal, permitting later reimplantation. CONCLUSIONS: We have adopted the American Heart Association indications and antimicrobial prophylaxis regimens recommended for prevention of endocarditis in patients with prosthetic values for patients with implanted insulin pumps.

DHEA-S plasma levels and incidence of Alzheimer's disease.

BACKGROUND: Cross-sectional studies controlling for age and gender reported a relationship between Alzheimer's disease and low dehydroepiandrosterone sulphate (DHEA-S) plasma levels. Prospective data with sufficient control for confounding factors are lacking. METHODS: A nested case-control study examined baseline DHEA-S in participants of the Berlin Aging Study. Cases (n = 14) developed dementia of the Alzheimer type within 3 years. Control group A (n = 14) was matched for gender, age, multimorbidity, and immobility. Control group B (n = 13) was matched for gender and age and comprised participants free from multimorbidity, immobility, multimedication, need of help, incontinence, visual impairment, hearing impairment, and depression. RESULTS: The mean plasma DHEA-S concentration of case subjects was 1.02 +/- 0.61 mumol/L. Both control groups had higher mean DEHA-S levels, in control group A, it was 1.89 +/- 1.24 mumol/L (p = .012) and in control group B 1.70 +/- 1.38 mumol/L (p = .093). CONCLUSIONS: This population-based prospective study supports the role of DHEA-S as a risk factor for Alzheimer's disease.

Screening an elderly population for verifiable adverse drug reactions. Methodological approach and initial data of the Berlin Aging Study (BASE).

Older adults are known to carry the largest risk for potential adverse drug reactions (ADR) due to the increased number of diseases and concurrent drug therapies. Prevalence rates of the most frequently used drugs in this population have already been evaluated, but the actual rates of specific drug-related risks (e.g., renal dysfunction) have not. Precise estimates of specific ADR risks rely on careful evaluation of the complete drug regimen for potential adverse effects, especially for elderly subjects. In addition, evaluations of manifest ADR have generally been based on reviews of individual medical records of self-reported symptoms. Systematic screening of a representative sample of elders for verifiable potential ADR has not been performed to date and is methodologically challenging. However, the present study attempts to assess both the prevalence of explicitly defined risks for known ADR and the corresponding co-occurrence of laboratory parameter alterations using a new approach. Initial findings are reported for a nearly-representative, age and sex stratified sample of 70 to 100+ year old subjects (n = 336) who participated in the Berlin Aging Study (BASE). Analyses focused on adverse drug effects on fluid and electrolyte balance and renal function. The results indicated an overall prevalence rate of 50% for selected ADR risks and a rate of 26% for the co-occurrence of corresponding laboratory alterations. By taking age into account, preliminary multivariate analyses did not support the hypothesis of increasing ADR susceptibility with advancing age.

Ventilatory capacity and risk for dementia.

BACKGROUND: Previous studies have found a relationship between single indicators of ventilatory capacity and measures of cognitive function, but have not addressed dementia specifically. This study examined the relationship between different indicators of ventilatory capacity and dementia, diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, controlling for important confounding factors. METHODS: Cross-sectional data on participants (n = 437) of the Berlin Aging Study (BASE), which are representative of former West Berlin's living population aged 70 years and older, were analyzed. Ventilatory capacity was measured by spirometry as peak expiratory flow rate (PEF-R), forced expiratory volume in 1 second (FEV-1), maximal expiratory flow at 50% of forced vital capacity (MEF50%FVC), and maximal expiratory flow at 25% of forced vital capacity (MEF25%FVC). Odds ratios (OR) for dementia associated with ventilatory capacity were obtained by logistic regression, adjusting for age, gender, education, ApoE4 status, chronic obstructive pulmonary disease, smoking, heart failure, visual and auditory functioning, grip strength, and former physical activity. RESULTS: Separate analyses for PEF-R, FEV-1, MEF50%FVC, and MEF25%FVC revealed significantly increased odds for dementia among subjects in the lowest compared with the best functioning group in ventilatory testing. The OR associated with PEF-R > or = 2 l/s was found to be 20.4 (confidence interval [CI] 5.1-82.7). For FEV-1, MEF50%FVC, and MEF25%FVC ORs of 7.5 (CI 2.1-27.9), 4.3 (CI 1.5-12.5), and 4.7 (CI 1.3-17) were obtained, respectively. CONCLUSIONS: Ventilatory capacity, measured by spirometry in a representative sample of very elderly people, is cross-sectionally related to dementia. Taking evidence from longitudinal studies into account, this result suggests that decreased respiratory function may increase the risk for dementia, independent from already known risk factors.

In an epidemiological sample the apolipoprotein E4 allele is associated to dementia and loss of memory function only in the very old.

The apolipoprotein E4 allele has been reported to be associated with late onset Alzheimer's disease. Here we report the relation of several neuropsychological test parameters and the diagnosis of dementia to the apolipoprotein E polymorphism in an epidemiological sample of 477 subjects aged 70-103 years. The apolipoprotein E4 allele was found to be associated with reduced performance in several sensitive neuropsychological memory tests and with diagnosis of dementia only in the oldest subjects (> 84 years). The association with dementia in this population based sample was much weaker than previously described and became only significant in a logistic regression analysis when age was included in the model.

Trace elements and carrier proteins in the aged.

Serum level of trace elements can be used as a marker for diagnosis and management of diseases. We evaluated the effects of age, sex and diurnal rhythm on serum concentration of Cu, Fe, Zn and their carrier proteins. The subjects (N=336) were participants of the randomized multidisciplinary Berlin Aging Study (BASE), stratified for age (70-103 yrs) and sex. There is no diurnal variation for the carrier proteins coeruloplasmin, transferrin and albumin. The age-related decline of these proteins is not significant. Not only serum Fe but also Zn levels undergo a progressive decrease during the day. In the aged the serum concentration of both trace elements decreased, but the most important changes are diurnal variations. To avoid mistakes in the interpretation of clinical findings, so called time-quantified reference values are recommended.

Atherosclerotic disease in very old age: Preliminary results from the Berlin aging study (base).

Prevalence rates of atherosclerotic diseases and its association to risk- and protective factors were analyzed in an age and gender stratified sample of a Berlin population of 70-103-year-old subjects (BASE: Berlin Aging Study). The investigation revealed three essential findings. (i) Age-specific differences in the prevalence rates of coronary heart disease and peripheral vascular disease were not detectable. (ii) Cerebrovascular disease was less frequent among subjects over 90 years compared to younger subjects. (iii) Some well documented risk factors of cardiovascular morbidity (hypertension, obesity, low serum HDL-cholesterol) appeared to be unrelated to atherosclerotic manifestations in advanced old age. Hypertension, elevated serum-cholesterol and male sex, however, were significantly associated with cerebrovascular disease, as was smoking and male sex with peripheral vascular disease. The relatively low number of persons diagnosed with cerebrovascular disease.in the highest age-group (90-103 years) was probably due to selective mortality. In summary, this univariate analysis confirmed associations between cardiovascular morbidity, and risk factors also in advanced old age.

[Telereha--special challenges for telemedicine in geriatric rehabilitation]. / Telereha--die besonderen Herausforderungen der Telemedizin im Geriatrisch-Rehabilitativen Umfeld.

Modern telecommunication technology has the potential to improve the quality of life for elders with physical and mental impairments as well as for their caregiving relatives. This can be viewed as an opportunity to establish and maintain instant and personalized access to various medical services in a situation where increasing needs are opposed to decreasing resources. However, it is not yet clear whether telematics is adequate, efficient, and effective in supporting care for geriatric patients. Results of a tele-rehabilitation project ("TeleReha", conducted at the Berlin Geriatric Center) which comprised mobility-impaired patients caregiving relatives and geriatric professionals, showed that participants regard telecommunicational and communicational needs.

[Diagnosis, prevention and therapy of osteoporosis]. / Diagnose, Prophylaxe und Therapie der Osteoporose.

Osteoporosis is a generalized osteopathy manifesting itself mainly in women beyond 60 years of age. We still lack a uniform definition of osteoporosis, generally defined as a decrease in bone mass in comparison with an age- and sex-related norm with normal mineralization of the remaining bone tissue. Of great importance for diagnosis are, above all, radiological procedures (plain X-rays of the spine, photon absorptiometry, computerised tomography), besides the medical history (backache, fractures) and the physical examination (kyphosis, shortening of the trunk, decrease in height). Furthermore, analyses of clinical chemistry and eventually histological examinations have to be applied for differential diagnostics with other generalized osteopathies and for etiological classification. The therapy of osteoporosis is supported by two main components: therapy of pain and influence on bone metabolism in order to diminish the risk of fractures. The position of fluorides in the treatment of osteoporosis is still under discussion. Most recent results recognize an alternative possibility by use of diphosphonates. Hormone substitution, physical training and nutritional aspects come to the fore in the prophylaxis of osteoporosis.

[Primary and secondary prevention in dyslipidemia in the elderly]. / Primär- und Sekundärprävention bei Dyslipidämie im Alter.

Cardiovascular disease (CVD) is the leading cause of mortality and a major cause of disability in advanced age. The relationship between coronary heart disease (CHD) and dyslipoproteinaemia is well known. The fact, however, that atherosclerosis is a systemic disease leads also to the consideration that patients suffering from cerebrovascular and peripheral arterial disease should benefit similarly from lipid lowering therapy as do patients with CHD. There is already growing evidence that the incidence of stroke may be markedly decreased by statin therapy. Though overall, the clinical significance of hypercholesterolaemia seems to decrease with increasing age, patients at age 65 to 75 tend to benefit even more than younger patients when elevated LDL-cholesterol is treated effectively. It should be noticed that prevention or postponement of cardiovascular events may also prevent premature functional limitations and disability in old age. Hence, it is suggested to screen elderly people with CVD for dyslipoproteinaemia and to treat elevated cholesterol levels by means of life style changes, nutritional therapy, and drug therapy. Treatment regimes should be considered depending upon complete risk stratification and geriatric assessment. Chronological age alone cannot be an argument to withhold a proven effective therapy from a growing segment of the population at risk.

[PEG tube placement in German geriatric wards - a retrospective data-base analysis]. / PEG-Sondenanlagen in der Deutschen Akutgeriatrie - Eine retrospektive Datenbank-Analyse.

The placement of a percutaneous endoscopic gastrostomy (PEG) is a safe and widely accepted method of artificial enteral nutrition. In Germany, PEG placement is performed approximately 140,000 times a year, about 65% of them in elderly patients. Yet indications for PEG placement in the elderly, as well as the health and functional status of these patients are unexplored in Germany. To draw conclusions about the indication for PEG placement, the health status and the further development of patients undergoing PEG in acute geriatric wards, we performed an analysis of the 2004 annual data set of the German Gemidas database. The Gemidas database is an instrument of voluntary quality assurance, where the treatment data of patients in German geriatric hospital units are registered. Data of 40 acute geriatric hospital units with 27,775 patients and 393 PEG tube placements were analyzed. According to the database items, we received information about the incidence of PEG placement, nutrition-relevant treatment diagnosis, patients age, functional and mental status, length of hospital stay, where patients were admitted from and discharged to and the hospital mortality of geriatric patients with and without PEG placement. In 1.4% of all treatment cases, a PEG was inserted. PEG placement was mainly performed in patients with the treatment diagnosis stroke (65.1%) and dysphagia (64.1%). The functional status of patients with PEG tube placement was very poor, with an Barthel Index of 8.2 (+/- 14.6) points at admission. Due to the severity of the disease and in concordance with existing data the overall hospital mortality of patients undergoing PEG placement was 17.6%, which is higher than in patients without PEG placement (4.3%). In all 27 775 analyzed geriatric patients, a diagnosis related to malnutrition was coded in only 7.0%, although sufficient data show a prevalence of about 50% in elderly hospital patients.

[Patient satisfaction and geriatric care - an empirical study]. / Patientenzufriedenheit in der Geriatrie - Eine empirische Untersuchung.

Patients' satisfaction has become a central concept in quality assurance. Despite progress in research in this area is still a lack of data for geriatric patients. Referring to the consumer model, satisfaction can be described as a difference between expectations and assessed performance. The aim of this study is to analyze satisfaction among geriatric patients in an in-patient setting. A personal interview was performed 1-2 days before discharge. Patients suffering for dementia or with problems to communicate were excluded. 124 of 268 geriatric patients who were discharged in 2003 were included (inclusion rate 46.3%). 119 were willing to participate (response rate 96.0%). Respondents were between 61 and 96 years old, 39% were male and 42% had serious functional limitations at time of admission. Multiple linear regression analysis revealed three significant predictors of a combined index of satisfaction and expectations: a) quality of hotel services; b) experience of neglect; c) provision of medical information and skills. In summary, standardized personal questionnaires can provide valid and reliable data of geriatric patients. Satisfaction of elderly patients is negatively affected by neglect and positively influenced by provision of medical information and a good hotel services.

[Important aspects of geriatric pharmacotherapy]. / Wichtige Aspekte der Pharmakotherapie beim geriatrischen Patienten.

Drug prescription for geriatric patients is one of the most prevalent yet also one of the most difficult interventions in geriatrics. Although this article focuses solely on specific important aspects of geriatric pharmacotherapy, medication in clinical practice is only one type of geriatric intervention that needs to be embedded in a well-coordinated bundle of multidimensional interventions addressing functional and psychosocial aspects alike. Not every older patient is per se a geriatric patient, nor is each geriatric patient per se of very old age. Therefore, this article initially proposes a clinical definition of the geriatric patient before summarizing the most significant physiological age changes affecting pharmacokinetics and pharmacodynamics as well as summarizing the most prevalent risks associated with the age-correlated increase in multiple drug use in order to describe the background from which general principles of geriatric pharmacotherapy have evolved. The quality of geriatric pharmacotherapy must not only be determined by avoidance of any kind of over medication, but also by the avoidance of under medication as well as the avoidance of inappropriate drugs for elderly patients. Treatment failures do not only result from mere polypharmacy, but can also be due to under utilization of drugs as well as due to the prescription of inappropriate medications. In fact, the problem of under medication in certain age-correlated diseases (e. g. depression, dementia, pain) has rarely been addressed systematically in clinical or epidemiological studies until now. In order to improve quality and safety of geriatric pharmacotherapy, a group of experts in the field developed a set of explicit age-adjusted criteria for potentially inappropriate drugs in 1991. These criteria have been regularly updated thereafter until 2003 and focus on age-related aspects of specific drugs and dosages as well as on co-morbid states and co-medications. As long as geriatric patients are rarely included in clinical trials on drug effectiveness and drug safety, these criteria should be applied and used in clinical practice at least to identify any demand for a detailed explicit justification of a therapeutic decision not in line with the explicit criteria in order to enhance safety of drug treatment in geriatric patients.

[Potential side-effects and interactions in multiple medication in elderly patients: methodology and results of the Berlin Study of Aging]. / Potentielle Neben- und Wechselwirkungen der Multimedikation im Alter: Methodik und Ergebnisse der Berliner Altersstudie.

Due to the age-associated increase in morbidity, many elderly subjects are in need of multiple drug treatment. Multimedications, however, carry a high risk for adverse drug reactions (ADR) and drug-drug interactions (DDI). This risk is especially increased in very old patients since age and morbidity lead to significant changes in body composition and organ functions. Nonetheless, representative and specific information on cumulative risks for adverse effects of multimedications in the aged is not yet available. We used data of the ongoing, population-based Berlin Aging Study (N = 516; age range 70-103 years) to evaluate the cumulative potential for ADR and DDI in a subgroup of participants taking five or more drugs (N = 221; 44.4% of the parent population [estimated]; mean age 85.2 +/- 8.3 years). Computerized algorithms were used to screen all medications for potential ADR and DDI based on standardized information which was derived from the German Physician's Desk Reference and a frequently used textbook on ADR and DDI. As expected, the analyses revealed a significant potential for adverse effects of multimedications. Cumulative totals of 12,221 different potential ADR (54.9 per subject) and 1016 different potential DDI (4.6 per subject) were identified. With regard to ADR, the most prevalent ADR-risks were for gastrointestinal upset (99%), headache (96%), postural hypotension (95%), and vertigo (94%). With respect to these risks, the minimum mean number of potentially offending drugs was 2.3, the maximum was 4.5 per subject. Additionally, 89% were at risk for drowsiness, 87% for blurred vision and 67% for confusion. Altogether, diuretics, digitalis and calcium antagonists accounted for 46% of ADR-risks. With regard to DDI, 85% had at least one drug-combination potentially leading to enhanced drug action, 52% had at least one combination potentially leading to reduced action. Most frequently involved in potential DDI were calcium antagonists (20%), digoxin (18%), and thiazides (17%). Most prevalent specific risks due to DDI were postural hypotension (48%), glycoside intoxication (26%), toxic CNS-effects (22%) and hypokalemia (19%). In conclusion, risks for ADR and DDI should be considered carefully and regularly monitored in elderly patients on multimedications. Stopping unnecessary medications, especially with regard to diuretics, digitalis and calcium antagonists, will lead to a marked reduction of the cumulative risks associated with multimedications in old age.

[Ambulatory geriatric rehabilitation--assessment of current status and prospects]. / Ambulante geriatrische Rehabilitation--Standortbestimmung und Perspektiven.

Clinical geriatrics in Germany has evolved remarkably since 1990, when first concepts had been developed for establishing structures and facilities for the ambulatory rehabilitation of geriatric patients. However, achievements during the last 10 years were made only for inpatient geriatrics and geriatric day clinics. Geriatric outpatient rehabilitation (GOR) is still a "missing link" in the networked care for elderly patients in Germany and remains until today in a planning phase. The article is aimed at describing the current organisational status of geriatric rehabilitation in Germany and focuses on the question of where and how to fit in geriatric outpatient rehabilitation. Distinction criteria between the different types of geriatric rehabilitation as well as indications, goals, and organisational aspects of GOR are discussed.

Pulmonary hemodynamic responses during superior mesenteric artery occlusion.

We investigated the possibility that the reestablishment of blood flow to the intestine after a 2-h occlusion of the superior mesenteric artery (SMA) may liberate vasoactive substances in quantities sufficient to cause pulmonary vasoconstriction. Experiments were conducted in dogs in which we compared the hemodynamic responses of the animal's left lower lung lobe (LLL), which was perfused at constant flow with blood pumped from the animal's pulmonary artery, with those of its intact right lung. Changes in systemic hemodynamics were similar to those reported by others for this stress. By 1 h after the release of the occlusion, cardiac output and stroke volume had fallen by 41.1 and 50.0%, respectively. Comparable changes were not observed in sham-operated control animals. Following the release of the occlusion, we observed an average 0.9 torr (P less than 0.10) increase in LLL arterial pressure, no significant changes in left atrial pressure, and a 11.9% increase (P less than 0.025) in LLL vascular resistance. In the intact right lung, no significant changes in pulmonary arterial pressure were observed at this time. Although the responses of the LLL suggested that some very small increase in vasomotor tone may have occurred, the small magnitude of the response indicated that the lung vasculature is only minimally affected during the early phases of this stress.

[Quality assurance in geriatric rehabilitation--approaches and methods]. / Qualitätssicherung in der geriatrischen Rehabilitation--Ansätze und Methoden.

It did not take the provisions of the 5th Book of the Social Code for quality assurance issues to gain significance in the field of geriatric rehabilitation as well. While in the surgical specialties, experience in particular with external quality assurance have already been gathered over several years now, suitable concepts and methods for the new Geriatric Rehabilitation specialty are still in the initial stages of development. Proven methods from the industrial and service sectors, such as auditing, monitoring and quality circles, can in principle be drawn on for devising geriatric rehabilitation quality assurance schemes; these in particular need to take into account the multiple factors influencing the course and outcome of rehabilitation entailed by multimorbidity and multi-drug use; the eminent role of the social environment; therapeutic interventions by a multidisciplinary team; as well as the multi-dimensional nature of rehabilitation outcomes. Moreover, the specific conditions of geriatric rehabilitation require development not only of quality standards unique to this domain but also of quality assurance procedures specific to geriatrics. Along with a number of other methods, standardized geriatric assessment will play a crucial role in this respect.

[The Geriatric Minimum Data Set (Gemidas) of the Federal Association of Clinical Geriatric Facilities e. V. as an instrument for quality assurance in inpatient geriatrics]. / Das Geriatrische Minimum Data Set (Gemidas) der Bundesarbeitsgemeinschaft der Klinisch-Geriatrischen Einrichtungen e.V. als Instrument der Qualitätssicherung in der stationären Geriatrie.

BACKGROUND: Geriatric medicine in Germany is faced with an increasing demand for continuous documentation and evaluation of its effectiveness and efficiency. Hence, the Federal Association (FA) of Clinical Geriatric Departments (Bundesarbeitsgemeinschaft der Klinisch-Geriatrischen Einrichtungen e.V.) has funded a working group on improving quality management in geriatrics by developing criteria for quality standards. METHODS: In 1996, the FA working group achieved consensus on the definition of the Geriatric Minimum Data Set (Gemidas) which covered (i) core information about a patient's age, sex, living arrangement, and (ii) basic characteristics of the hospital course such as location prior to admission and past discharge, leading and accompanying diagnoses, newly prescribed technical aids, objective functional status on admission and at discharge (e.g., Barthel Index (BI), Timed Up & Go (TUG), and intensity of professional care (PPR)), as well as subjectively evaluated attainment of treatment goals. This initial report describes the instrument and presents analyses of its feasibility for routine clinical practice and data consistency. RESULTS: Twenty out of 27 hospitals (74%) integrated Gemidas successfully in daily routine, 75% of which (15 hospitals, total n = 10,567 patients) instantaneously collected data on constant numbers of patients per month. Multivariate regression analyses used to decompose variances of the instrument's central indicators (e.g., BI, TUG, PPR) revealed a satisfactory dimensionality and high consistency (e.g., covering 59% of variance in BI with 53% of variance uniquely attributable to patient characteristics), as well as sensitivity to differences between hospitals (e.g., 12% of variance in duration of stay uniquely attributable to hospital differences after controlling for patients' characteristics). CONCLUSION: Gemidas appears to be a feasible quality assurance instrument in geriatrics, suitable for compiling its data into a central registry database, which may then be used for analyses across and between hospitals. However, some modifications are still necessary and more detailed analyses needed, before final recommendations can be made.

The impact of somatic morbidity on the Hamilton Depression Rating Scale in the very old.

The Hamilton Depression Rating Scale (HDRS) is world-wide the most important observer rating scale for depression. Many items of this scale refer to somatic symptoms of depression which cast doubt on the validity of HDRS scores in the presence of somatic comorbidity as, for example, in elderly patients. The present study, therefore, was planned to investigate the validity of the HDRS in cases in which the patient is suffering from a depressive illness together with somatic illnesses. The study population (n = 516) is a representative sample of citizens aged 70 years and older in West Berlin. They were assessed independently by internists and psychiatrists. Each positive item of the HDRS scale was then rated by the internists as to what degree it reflects somatic morbidity. Results show that multimorbidity interferes with the validity of the HDRS. There were 8 items for which more than half of all positive scores as rated by psychiatrists were seen by the internists as being possibly related to somatic disorders. Patients with corrections in the HDRS score showed a somewhat increased rate of medicines and cardiovascular diagnoses. There was less ambiguity for items with greater severity.