[Diabetes care and incidence of severe hypoglycemia in nursing home facilities and nursing services: The Heidelberg Diabetes Study]. / Behandlungsqualität des Diabetes mellitus und Inzidenz schwerer Hypoglykämien in stationären und ambulanten Versorgungseinrichtungen: Heidelberger Diabetesstudie.

AIM: The goal of this study was to perform a structured analysis of the treatment quality and acute complications of geriatric patients with diabetes mellitus (DM) cared for by nursing services and nursing home facilities. Secondly, structural problems and potentials for improvement in the care of multimorbid older people with DM treated by nursing homes and nursing services were analysed from the viewpoint of geriatric nurses, managers of nursing homes and general practitioners. METHODS: In all, 77 older persons with DM from 13 nursing homes and 3 nursing services were included in the analysis (76.6% female, HbA1c 6.9 ± 1.4%, age 81.6 ± 9.9 years). Structural problems and potentials for improvement were collected from 95 geriatric nurses, 9 managers of nursing homes and 6 general practitioners using semistandardized questionnaires. RESULTS: Metabolic control was too strict in care-dependent older people with DM (mean HbA1c value: 6.9 ± 1.4 %; recommended by guidelines: 7-8%). The measurement of HbA1c was performed in 16 of 77 people (20.8%) within the last year despite a high visitation frequency of the general practitioners (12.7 ± 7.7 within the last 6 months). The incidence of severe hypoglycemia was 7.8%/patient/year. Regarding the management in case of diabetes-related acute complications 33 geriatric nurses (34.7%) stated not having any written standard (nursing home 39%, geriatric services 16.7%). CONCLUSION: Complex insulin therapies are still used in older people with DM with the consequence of a high incidence of severe hypoglycemia. Concrete management standards in the case of diabetes-related acute complications for geriatric nurses are lacking for more than one third of the nursing services.

[Palliative care for patients with dementia]. / Palliativversorgung von Menschen mit Demenz.

Patients with dementia are an important target group for palliative care since particularly in advanced stages and at the end of life they often have complex health care and psychosocial needs. However, people with dementia have inappropriate access to palliative care. So far, palliative care focuses on cancer patients. Among other reasons, this is due to the different illness trajectories: while in cancer a relatively clear terminal phase is typical, in dementia functional decline is gradual without a clear terminal phase, making advanced care planning more difficult. Good communication among health care providers and with the patient and his/her family is essential to avoid unnecessary or even harmful interventions at the end of life (e.g., inserting a percutaneous endoscopic gastrostomy, PEG). To maintain the patient's autonomy and to deliver health care according to the individual preferences, it is important to appropriately inform the patient and the family at an early stage about the disease and problems that may occur. In this context, advanced directives can be helpful.

[Diabetes and dementia]. / Diabetes und Demenz.

Diabetes mellitus is a known risk factor for cognitive dysfunction and dementia. Chronic hyperglycemia, genetic predisposition, arterial hypertension, hyperlipoproteinemia, micro- and macrovascular diseases, and depression play a major role in the development of cognitive dysfunction. Both pathophysiology of diabetes and dementia and the specifics of diabetes therapy in patients with dementia are presented in this review.

[Acute illness and depression in the elderly and the influence of cognitive impairment : AIDE-cog trial]. / Komorbidität von Depression und Demenz bei geriatrischen Patienten mit akuter körperlicher Erkrankung: AIDE-cog-Studie.

Geriatric patients with acute somatic illness have a high comorbidity of depression and dementia. The following differential diagnoses have to be discerned: pseudodementia in acute depressive states, depression as a risk factor for dementia, and a depressive episode in the early stage of dementia. For both the symptoms and the trigger factors of these differential diagnoses the overlap and the particularities were qualitatively examined in the AIDE-cog (Acute Illness and Depression in Elderly cognition) trial. A second prospective randomized controlled part of the AIDE-cog trial quantitatively evaluated the influence of cognitive impairment in geriatric patients with an acute somatic illness and comorbid depression on the therapeutic effect of cognitive behavioral therapy. A preliminary analysis shows that already in early dementia the therapeutic effects are inferior. Other psychotherapeutic methods that address the remaining cognitive and emotional functions in dementia must be evaluated.

[Diabetes and cardiovascular diseases in old age]. / Diabetes und kardiovaskuläre Erkrankungen im Alter.

The treatment of cardiovascular diseases in diabetic geriatric patients needs an individual risk-benefit analysis. The overtreatment of hyperglycemia in the sense of metabolic control that is too tight (HbA(1)c level <6%) may lead to increased mortality. As a rule, the target HbA(1)c level in geriatric patients with diabetes mellitus should be between 7 and 8%.

[Palliative geriatrics. What are the differences between oncologic and non-oncologic palliative geriatric inpatients?]. / Palliative Geriatrie. Wie unterscheiden sich onkologische von nichtonkologischen geriatrischen Palliativpatienten im Krankenhaus?

AIM OF THE STUDY: Analysis of differences between oncologic and non-oncologic patients in the first German hospital-based special care unit for palliative geriatrics. METHODS: Systematic analysis of patients' records according to a standardized protocol. RESULTS: A total of 217 patients from a hospital-based special care unit for palliative geriatrics (56.7% women, 43.4% men) were included over a retrospective period of 1.5 years. Patients were categorized as non-oncologic (53.4%, n=116) or oncologic (46.5%, n=101). Non-oncologic patients were older than oncologic patients (84.0 vs. 76.8 years, p=0.02), and showed a higher degree of functional dependence (p<0.001) and mortality (87.1% vs. 53.3%, p<0.001). The two most common non-oncologic categories of primary diagnoses were pulmonary and neurologic diseases: 19% each. Certain secondary diagnoses had a higher incidence with non-oncologic than oncologic patients, such as pulmonary disease (39% vs. 24%, p=0.02) and dementia (38% vs. 8%, p<0.001). The Charlson comorbidity index was found to be higher for oncologic patients than for non-oncologic patients (6.6 vs. 4.1, p=0.001). Non-oncologic patients also experienced more dysphagia (57% vs. 17%, p<0.001), NPO (43% vs. 12%, p<0.001), and tube or parenteral feeding (31% vs. 9%, p=0.001). Oncologic patients experienced more often symptoms of pain, constipation, agitation, diarrhea, vomiting, and nausea. CONCLUSION: There are clinically relevant differences between oncologic and non-oncologic palliative geriatric inpatients regarding the constellation of symptoms, care, mortality, and the prevalence of concerns about hydration and feeding. These differences ought to be taken into account for further education, as well as further improvement of the healthcare system, to enable an appropriate standard of palliative care for geriatric patients.

[Treatment quality in geriatric patients with diabetes mellitus in various home environments]. / Behandlungsqualität bei geriatrischen Patienten mit Diabetes mellitus in verschiedenen häuslichen Versorgungsstrukturen.

OBJECTIVE: The goal of the present study was to systematically assess treatment quality, perceptions, and cognitive function of elderly patients with diabetes admitted to an acute geriatric hospital from different home environments (nursing home residents, home care, assisted living, family caregivers, self-sufficient). METHODS: Quality of diabetes treatment, metabolic control (HbA(1c)), nutrition, treatment satisfaction, cognition, disability, and level of dependency were assessed in 128 patients with diabetes. RESULTS: Out of 128 patients, 87 patients (68%) showed an HbA1c≤8% according to the guidelines for aging people with diabetes of the German Diabetes Association (DDG). Compared to patients living independently at home, the metabolic control in nursing home residents and their treatment satisfaction were as good. They had a higher degree of dependency though (Barthel, p<0.001), more strongly impaired mobility (Tinetti, p<0.01), less diabetes knowledge (p<0.001), inferior cognitive performance (MMSE, SPMSQ, p<0.01), and a higher prevalence of depression (GDS) (p<0.01). Better cognitive function correlated with better diabetes knowledge (r=0.49; p<0.001), but not with better metabolic control. CONCLUSION: The treatment of geriatric patients with diabetes mellitus requires individual considerations and interdisciplinary care. Particularly the continuing education of geriatric nurses could contribute to improved diabetes treatment quality in nursing home residents.

[Complaints under analgesics: the difficult interpretation by older patients]. / Beschwerden unter Analgetika: Uber die schwierige Interpretation bei älteren Patienten.

BACKGROUND: Older patients, particularly those with multimorbidity, complain about many symptoms which also occur under analgesics (especially with opioids). The goals of the study were to quantify symptoms and discuss the relationships to analgesics, pain, multimorbidity, function, age and gender. PATIENTS AND METHODS: On admittance to geriatric hospital, 1700 consecutive inpatients were questioned about symptoms typically of side-effects of analgesics and pain. Additionally medication including analgesics, activities of daily living, orientation, age, gender and morbidity were recorded. RESULTS: Of the patients, 1,418 (mean age 80.9 years) could answer questions about symptoms. Disturbance of sleep (n=664, 46.8%), pain (n=609, 43.0%), low appetite (551, 37.4%), dizziness (482, 34%), tiredness (331, 19.7%), constipation (236, 16.6%) and problems of urination (213, 12.7%) were indicated most frequently. Univariate analysis showed the well known correlations of analgesics and symptoms to be dependent on dose and substances. However, using a multivariate model, analgesics lost the significance for the symptoms with some exceptions. Pain intensity, duration of pain and gender differences became more important. Vomiting, dry mouth, and problems with urination correlated with low levels of activities of daily living. Increasing morbidity and cognitive deficits were not important for many symptoms. CONCLUSIONS: Our results underline the difficult interpretation of symptoms as a side-effect of analgesic treatment in older patients. Pain and gender differences have to be considered. The recommendation to carefully record symptoms before analgesic treatment is supported by our results.

Designing studies on the effectiveness of physical training in patients with cognitive impairment.

The literature provides conflicting results on the effectiveness of physical training in cognitively impaired older individuals. Cognitive impairment has been shown to be a negative predictor of rehabilitation outcome in these persons. However, the evidence on which this discussion is based is scarce. The methodology used in previous studies shows substantial shortcomings. The presented study protocol documents the methodology of one of the largest intervention studies worldwide in this research field with a standardized specific training program in cognitively impaired subjects including short- and long-term follow-up examinations. The selected sensitive evaluation tools for motor, cognitive and emotional status have all been validated for use in older persons. Most of these tests have been validated in cognitively impaired persons. In contrast to most previously published RCTs only study participants within a comparable level of cognitive impairment will be included in the study. The primary aim of the study is to evaluate a specific training program to improve motor performance (strength and functional performance) in persons with cognitive impairment. Secondary study endpoints include the reduction of falls, improvement of cognitive as well as psychological status and the documentation of physical activity. The training program is based on previous successful intervention studies of the research group, was complemented and modified with respect to specific deficits of cognitively impaired persons and focuses on motor improvements. The article gives a rationale for interventions using physical training and study methodology in persons with dementia.

Repressive coping in geriatric patients' reports - impact on fear of falling.

We investigated the influence of repressive coping, depression, cognition, education and age on geriatric patients' reports on health-related status in 80 geriatric patients with a history of injurious falls. For patient reports, subjective statements on activity avoidance, perception of terminal decline, falls, and fear of falling were assessed. Co-morbidity and number of medications were documented based on patient charts. Repressive coping was significantly associated with underreporting in geriatric patients in all items documented and predicted most variables of patients' reports. Because of underreporting significant health problems geriatric patients with repressive coping may therefore be at risk for inadequate medical treatment.

Prolonged activation EEG differentiates dementia with and without delirium in frail elderly patients.

OBJECTIVE: Delirium in the elderly results in increased morbidity, mortality and functional decline. Delirium is underdiagnosed, particularly in dementia. To increase diagnostic accuracy, we investigated whether maintenance of activation assessed by EEG discriminates delirium in association with dementia (D+D) from dementia without delirium (DP) and cognitively unimpaired elderly subjects (CU). METHOD: Routine and quantitative EEG (rEEG/qEEG) with additional prolonged activation (3 min eyes open period) were evaluated in hospitalised elderly patients with acute geriatric disease. Patients were assigned post hoc to three comparable groups (D+D/DP/CU) by expert consensus based on DSM-IV criteria. Dementia diagnosis was confirmed using cognitive and functional tests and caregiver rating (IQCODE, Informed Questionnaire of Cognitive Decline in the Elderly). RESULTS: While rEEG at rest showed low accuracy for a diagnosis of delirium, qEEG in DP and CU revealed a specific activation pattern of high significance found to be absent in the D+D group. Stepwise logistic regression confirmed that differentiation of D+D from DP was best resolved using activated upper alpha and delta power density which, compared with rEEG, enabled an 11% increase in diagnostic correctness to 83%, resulting in 67% sensitivity and 91% specificity. Among frail CU and D+D subjects, almost 90% were correctly classified. CONCLUSION: Dementia associated with delirium can be discriminated reliably from dementia alone in a meaningful clinical setting. Thus EEG evaluation in chronic encephalopathy should be optimised by a simple activation task and spectral analysis, particularly in the elderly with dementia.

[3rd Workshop on Epidemiology, Prevention and Treatment of Invasive Meningococcal Disease in Würzburg 2006]. / 3. Würzburger Workshop zur Epidemiologie, Prävention und Therapie der invasiven Meningokokkenerkrankung 2006.

On October 5th, 2006, the German Reference Centre for Meningococci (NRZM) held the 3rd Workshop on Epidemiology, Prevention and Treatment of Invasive Meningococcal Disease, in collaboration with the German Society for Hygiene and Microbiology (DGHM). Given the recent recommendation of the German Standing Committee on Vaccination (STIKO) for conjugate meningococcal C vaccination of all children in the second year of life, observations from meningococcal C conjugate vaccination campaigns in other European countries were presented and compared to the German situation. Moreover, the newly implemented cluster detection routines employed at the NRZM and their integration into the interactive geographical information system EpiScanGIS were shown. Based on recent experiences from regional outbreaks in Oberallgäu, Sangerhausen, and Greater Aachen, examples for public health intervention were given at the conference. In addition, current developments in the area of meningococcal research, as well as trends in antimicrobial susceptibility were covered. Finally, the latest evidence concerning the clinical management and chemoprophylaxis of this invasive bacterial disease was discussed.

["FRAGILE"-Old people and surgery]. / "FRAGILE"--Der alte Mensch und die Chirurgie.

As life expectancy and modern surgical and intensive care techniques develop, the number of old patients in surgery is rising. Associated are problems with the indication for surgical intervention and rising incidence of "typical" peri- and postoperative complications such as postoperative delirium. Geriatric assessment serves to identify patients at risk of developing complications, to describe the postoperative course of functional and cognitive abilities, and to adjust therapeutic strategies to the individual needs of these patients. The most important instruments of geriatric assessment are described. Postoperative delirium, the most prevalent complication in surgical geriatric patients, is discussed in detail with regard to risk factors, prevalence, diagnosis, and therapeutic options.

Salt and hypertension: data from the "Heidelberg Study".

Prevalence of hypertension and "intake" of sodium chloride (as estimated from 24-hr urinary Na-excretion) were measured in a random sample (n = 800) of 20- to 40-year-old Heidelberg men. There was a high (14%) prevalence of hypertension and a high (mean = 11.32 g) NcCl intake; both showed, however, no correlation. The lack of a NaCl/blood pressure correlation in this cross-sectional study might be due to intra- and interindividual variability of both parameters and, possibly, to a "threshold" argument concerning the etiological role of sodium in hypertension.

Sitosterol in juvenile type II hyperlipoproteinemia.

The effect of beta-sitosterol on plasma lipids and lipoproteins was evaluated in a randomized double-blind cross-over trial in 15 children and adolescents with familial hypercholesterolemia over a period of 6 months. Twelve patients completed the study, with good adherence to drug intake. Sitosterol lowered the plasma total choelsterol by 6%, LDL cholesterol by 7% and HDL cholesterol by 15% (P less than 0.05). This insufficient response of total and LDL cholesterol and the marked fall of HDL cholesterol appears to advise against the use of beta-sitosterol granulate in juvenile type II hyperlipoproteinemia.

"Low dose" colestipol in children, adolescents and young adults with familial hypercholesterolemia.

The effect of colestipol on plasma lipids and lipoproteins was studied in children, adolescents and young adults with familial hypercholesterolemia. O.125 g or 0.25 g/kg body weight were given in randomized sequence for period of 4 weeks. Total cholesterol was lowered by 13 and 18% with the smaller and larger dose , respectively, and LDL cholesterol lowered by 15% with the smaller and 12% with the larger dose. HDL cholesterol rose by 18 an 32%. LDL composition before and during the study was abnormal due to a markedly reduced triglyceride content. "Low-dose" colestipol is less effective lowering total plasma and LDL cholesterol than conventional doses but may, due to very few side effects, by advantageously used in cases of familial hypercholesterolemia when plasma cholesterol levels after dietary management are only 15-20% above normal.

Reduced LDL- and increased HDL-apoproteins in patients with hypercholesterolaemia under treatment with bezafibrate.

The effect of bezafibrate on serum lipids, lipoproteins and the apoproteins A-I, A-II and B was studied in 18 patients with primary hypercholesterolaemia. Total cholesterol was lowered by 20% (P less than 0.05), LDL-cholesterol by 24% (P less than 0.05), and apo B by 14% (P less than 0.05), which is comparable to the effect obtained with anion exchange resins but with far fewer side-effects. HDL increased significantly during bezafibrate treatment both by measurement of HDL-cholesterol (+54%, P less than 0.05) and by the determination of HDL-apoproteins A-I (+ 19%, P less than 0.05) and A-II (+ 23%, P less than 0.05). This increase of HDL and the decrease of triglycerides was maintained for 6 weeks of placebo treatment after cessation of bezafibrate, while serum total and LDL cholesterol as well as apo B returned to their baseline levels.

Acute dietary effects on diurnal plasma lipids in normal subjects.

The effects of different dietary carbohydrates and different dietary fats as well as of differently spaced dietary constituents on 24-h plasma free fatty acids and triglycerides were determined in healthy young males. If, in an isocaloric diet containing 15-20% protein, 37% fat and 43--48% carbohydrates, sucrose is compared with glucose, 24-h plasma triglycerides are significantly higher with the former carbohydrate. When palm oil (mainly 16 : 0 fatty acids) is compared with olive oil (mainly 18 : 1 fatty acids), 24-h triglycerides are significantly higher with the latter. If the carbohydrate component of a mixed meal is removed, alimentary lipemia is considerably greater. Our findings supplement long term studies regarding the effect of different dietary fats and carbohydrates on plasma lipids and allow calculation of "upper normal limits" for 24-h plasma triglycerides and free fatty acid patterns on isocaloric diets of "prudent" composition.

Influence of diet on high-density lipoproteins.

Evidence of a relation between diet and high-density lipoprotein (HDL) levels in humans comes from numerous cross-sectional and experimental studies. Evaluation of data from cross-sectional nutrition and health surveys sometimes yields different results for men and women but usually demonstrates positive correlations of HDL cholesterol levels with total energy intake, alcohol consumption, dietary cholesterol and total and animal fat, and negative correlations of HDL with dietary carbohydrates (simple sugars) and, in some instances, plant fats. Short-term dietary manipulation produced confirmatory evidence of a causal relation between diet and HDL with regard to several of these factors; however, there are few long-term data. The underlying mechanisms as well as the relation of HDL manipulation to cardiovascular health are still to be defined, particularly because the functions and fates of the HDL molecule may vary according to its composition and turnover, which are not reflected by the HDL cholesterol concentration. Furthermore, some relations between diet and HDL may only be the result of other metabolic consequences of dietary change, for instance, triglyceride metabolism and other lipoproteins. Although there is consistent evidence that a high HDL cholesterol level is indicative of a low risk of coronary heart disease in industrialized populations, evidence is inconclusive that manipulation of HDL leads to an alteration of risk.

Measurement of drug compliance by continuous electronic monitoring: a pilot study in elderly patients discharged from hospital.

OBJECTIVE: A pilot study to assess patient compliance with medication by using a new measurement technique, continuous electronic monitoring. DESIGN: Survey. Compliance monitors were provided to eligible patients at discharge from the hospital to measure drug intake behavior prospectively for a period of 3 weeks. SETTING: Ambulant patient care after discharge from a geriatric hospital, Krankenhaus Bethanien, which is affiliated with the University Clinic, Heidelberg. PATIENTS: A consecutive convenience sample of 18 independently living elderly patients (median age 76 years) completed the study. The patients were on maintenance therapy with cardiac glycosides and/or potassium-sparing diuretics prescribed to be taken once daily. INTERVENTION: The monitoring method provides information about patients' real timing of drug use by continuously recording date and time of openings and closings of the medication containers (monitors). In addition to a standard measure, the percentage of prescribed doses taken, information about regularity of drug use is obtained. RESULTS: Compliance, percentage of prescribed doses taken, was remarkably variable; it ranged from 24% to 100%, 95% CI: 62%-84%. Mean compliance declined from the first to the third week after discharge, 85% vs 69%, 95% CI: 74%-95% and 56%-81%, respectively (P < 0.05). Omissions of doses, the predominant pattern of non-compliance, were observed in 17 of 18 patients. Regularity of dose timing, as defined by the number of interdose intervals within 24 h +/- 15%, varied from 10% to 100%, 95% CI: 46%-76%. CONCLUSIONS: Continuous electronic monitoring revealed highly variable compliance in patients prescribed maintenance therapy. Even with a once-daily regimen, persistent and high compliance cannot be assumed. The monitoring technique may be of great value to research and, possibly, to practical therapeutic management.