Home treatment for acute mental healthcare: randomised controlled trial.

BACKGROUND: Home treatment has been proposed as an alternative to acute in-patient care for mentally ill patients. However, there is only moderate evidence in support of home treatment. AIMS: To test whether and to what degree home treatment services would enable a reduction (substitution) of hospital use. METHOD: A total of 707 consecutively admitted adult patients with a broad spectrum of mental disorders (ICD-10: F2-F6, F8-F9, Z) experiencing crises that necessitated immediate admission to hospital, were randomly allocated to either a service model including a home treatment alternative to hospital care (experimental group) or a conventional service model that lacked a home treatment alternative to in-patient care (control group) (trial registration at ClinicalTrials.gov: NCT02322437). RESULTS: The mean number of hospital days per patient within 24 months after the index crisis necessitating hospital admission (primary outcome) was reduced by 30.4% (mean 41.3 v. 59.3, P<0.001) when a home treatment team was available (intention-to-treat analysis). Regarding secondary outcomes, average overall treatment duration (hospital days + home treatment days) per patient (mean 50.4 v. 59.3, P = 0.969) and mean number of hospital admissions per patient (mean 1.86 v. 1.93, P = 0.885) did not differ statistically significantly between the experimental and control groups within 24 months after the index crisis. There were no significant between-group differences regarding clinical and social outcomes (Health of the Nation Outcome Scales: mean 9.9 v. 9.7, P = 0.652) or patient satisfaction with care (Perception of Care questionnaire: mean 0.78 v. 0.80, P = 0.242). CONCLUSIONS: Home treatment services can reduce hospital use among severely ill patients in acute crises and seem to result in comparable clinical/social outcomes and patient satisfaction as standard in-patient care.

Referral to Inpatient Treatment Does not Necessarily Imply a Need for Inpatient Treatment.

We analyzed the dispositional decisions taken in a unit for clinical decision making (UCDM) which was set up to examine all emergency inpatient referrals to a psychiatric hospital. Hospitalization proved unnecessary for at least 17 % of the N = 2,026 inpatient referrals over a one year period. Instead, these patients were admitted to day-hospitals or outpatient treatments, resulting in annual cost savings of approximately 3.3 million. Merely 8 % of those non-admitted patients had to be hospitalized within 28 days of the decision for non-admission being taken. Thus, a specialized UCDM run by clinical experts can help identify cost-effective alternatives to hospitalization.

Dementia diagnostics in primary care: a representative 8-year follow-up study in Lower Saxony, Germany.

AIM: To investigate whether primary-care physicians' competency regarding dementia diagnostics improved from 1993 to 2001. METHODS: In a representative follow-up survey 122 out of 170 (71.8%) family physicians (FPs) were randomly assigned to 2 written case samples presenting patients with slight memory impairment (case 1a: female vs. case 1b: male) and moderate dementia [vascular type (case 2a) vs. Alzheimer's disease (case 2b)]. Potential diagnostic workup was inquired by a structured face-to-face interview. RESULTS: 'Basic' diagnostics like history taking or laboratory investigations were considered in the first place. In case 1, neuropsychological screening was significantly more frequently considered at follow-up (19.3% in 1993 vs. 31.1% in 2001); it still would have been applied rarely in case 2 (2a: 14.1 vs. 14.8%; 2b: 23.5 vs. 24.6%). Neuroimaging remained not to be considered as a standard procedure, and only a minority of FPs would have performed a screening for depression (2001: 1a: 6.7%; 1b: 11.3%; 2a: 0.0%; 2b: 1.6%). CONCLUSIONS: With regard to dementia diagnostics in primary care, guideline adherence remained low at follow-up. Structured training efforts aiming at FPs appear to be necessary.

Abeta peptide 1-42, Tau protein and S-100B protein level in cerebrospinal fluid of three patients with primary progressive aphasia.

Primary progressive aphasia (PPA) is a clinical syndrome characterized by a slowly progressive aphasia in the absence of accompanying signs of generalized dementia. While non-fluent PPA tends to progress frontally and is usually linked to frontotemporal degeneration, fluent PPA might be associated with both, frontotemporal degeneration or Alzheimer's disease. Although recent reports suggest that PPA belongs neuropathologically to the group of tauopathias, cerebrospinal fluid analysis has not been established as a means of diagnosis in PPA so far. In this paper we investigated Abeta peptide(1-42) (Abeta(1-42)), Tau protein and S-100B protein level in the cerebrospinal fluid of three patients with PPA. In all patients Tau protein and S-100B level were slightly elevated, however, Abeta(1-42) was found to be in normal range. Thus, our first results point to PPA being neurochemically linked to frontotemporal degeneration.

[Changes of the psychogeriatric inpatient care at the University Psychiatric Hospitals in Basel following the constitution of an outpatient care service for the elderly]. / Veränderungen der stationären gerontopsychiatrischen Versorgung an den Universitären Psychiatrischen Kliniken in Basel nach Etablierung eines Ambulanten Dienstes Alterspsychiatrie (ADA).

OBJECTIVE: 10-year follow-up of the psychogeriatric inpatient care at the University Psychiatric Hospitals Basel following the establishment of an outpatient care service for the elderly (ADA). METHOD: Standardized chart review of a random sample of psychogeriatric cases (≥ 65 y) of the years 1997 and 2007 (n = 100 each) in terms of socio-demographic, diagnostic, therapeutic und administrative data. RESULTS: The number of patients with contact to both inpatient and outpatient services prior to admission increased. There was no change regarding the amount of unvoluntary admissions. As expected more complex cases were treated. The case management showed changes towards greater guideline conformity. CONCLUSION: The 10-year follow-up shows a better outpatient treatment and the provision of inpatient facilities for complex multimorbid and emergency patients.

Primary care physicians' attitudes related to cognition enhancers in early dementia: a representative eight-year follow-up study in Lower Saxony, Germany.

OBJECTIVE: By means of a representative follow-up survey, we investigated changes in family physicians' (FPs) attitudes towards cognition enhancers in early dementia during 1993 and 2001. METHODS: One hundred and twenty-two FPs (response rate 71.8%) in Lower Saxony, Germany, were randomly assigned to one of two written case samples presenting a patient with cognitive decline suggestive of early Alzheimer's disease (DAT; case A: female patient vs case B: male patient). Using a structured face-to-face interview, they were asked to suggest their potential drug treatment. The results were compared to corresponding data from our previous survey in 1993. RESULTS: FPs' readiness to start antidementia drug treatment decreased from 70.4% in 1993 to 43.4% at follow-up, although underlying DAT was significantly more frequently suggested (11.0% vs 26.2%, p < 0.05). Substances with questionable efficacy such as Piracetame were prescribed less frequently in 2001 whereas evidence-based medication like cholinesterase inhibitors (ChEIs) failed to compensate for this drop. Compared to 1993, when 55.2% of FPs expected no therapeutic impact, at follow-up, 75.4% expected slowdown of disease progression, stabilisation or improvement of symptoms (p < 0.05). CONCLUSIONS: Our results demonstrate a significant decrease of therapeutic nihilism in primary care within eight years. However, in patients with suspicion of DAT, this is not reflected accordingly in potential treatment.

[Physicians' competence regarding the early diagnosis of dementia: differences between family physicians and primary care neuropsychiatrists in Germany]. / Die Frühdiagnose der Demenz in der Praxis niedergelassener Arzte: Unterschiede zwischen Haus- und Fachärzten in Deutschland.

OBJECTIVE: Are there any differences between family physicians (FP) and primary care neuropsychiatrists (NP) with regard to their diagnostic competence of early dementia? METHODS: Trained interviewers presented written case vignettes to 68 NP and 122 FP during a structured interview. The case history described an otherwise healthy 70 years old patient complaining about cognitive disturbances suggesting incipient dementia. RESULTS: The survey is representative with a high response rate (71.8% FP and 67.3% NP). In both physician groups a vascular disease concept prevailed although the patient had no vascular risk factors. For primary and differential diagnosis NP considered depression more often. Overall only about 50% of physicians considered Alzheimer dementia. Regarding diagnostic methods the NP adhered significantly better to the current guidelines. While 31% of FP would apply dementia screening and 12% order neuroimaging, 76% and 74% of the NP mentioned these methods, respectively. CONCLUSIONS: There are negligible differences between NP and HA with regard to early diagnostic awareness of dementia. Vascular concepts prevail. However, both groups differ with regard to the diagnostic work-up. An increase of competence seems to be necessary in both groups.

Diagnosis of dementia in primary care: a representative survey of family physicians and neuropsychiatrists in Germany.

AIM: To measure the diagnostic competence of family physicians (FP) and neuropsychiatrists (NP) for moderate dementia. METHODS: Written case vignettes describing moderate dementia either of Alzheimer type or vascular type were randomized to a representative sample of 122 FP and 68 NP, corresponding to response rates of 71.8 and 67.3%, respectively. They served as the basis for a structured face-to-face interview. RESULTS: NP and FP did not differ with regard to their diagnostic considerations, however, concerning diagnostic workup. Vascular dementia was much better recognized than dementia of Alzheimer type. Neuropsychological tests and brain imaging would be done by 14.8 and 32.8% of the FP in the case of vascular dementia. In Alzheimer dementia they would apply these methods in 24.6 and 19.7%, respectively. The corresponding numbers for NP were about 60% in both cases for testing and more than 80% for brain imaging. CONCLUSIONS: There is still a wide gap between guidelines and practice in primary care. The apparent overdiagnosis of vascular dementia may be one reason for the low drug treatment rates.

Early diagnosis of dementia in primary care: a representative eight-year follow-up study in Lower Saxony, Germany.

OBJECTIVE: To investigate whether primary care competency in early diagnosis of dementia might have changed during 1993 and 2001. METHOD: By means of a representative follow-up survey 122 out of 170 (71.8%) family physicians (FPs) in Lower Saxony, Germany, were randomly assigned to two written case samples presenting a patient with mild cognitive impairment (case 1a vs. 1b: female vs. male patient) and moderate dementia (case 2a vs 2b: vascular type (VD) vs Alzheimer's disease (DAT)), respectively. By means of a structured face-to-face interview, they were asked for their diagnostic considerations. RESULTS: In comparison to 1993, dementia was significantly more frequently considered. However, there was a striking tendency in overestimating vascular aetiology and under-diagnosing probable DAT (case 1a/1b: DAT: 11.0% in 1993 vs 26.2% in 2001; VD: 2.1% in 1993 vs 17.2% in 2001). As a possible contributor to a dementia syndrome, concomitant medication was considered only exceptionally (case 2a/2b: 4.4% in 1993 vs 2.5% in 2001). Physicians above 50 years of age showed a significantly lower early diagnostic awareness. At follow-up, the presumed interest in geriatric (psychiatric) topics dramatically faded from 66.9% to 35.2%. CONCLUSIONS: Our results demonstrate a persistent need of training efforts aiming at the early recognition of dementia, especially of DAT, in primary care.