General practitioners' perspectives on lifestyle interventions for cognitive preservation in dementia prevention.

BACKGROUND: General practitioners (GPs) play a crucial role in identifying cognitive impairment and dementia and providing post-diagnostic care. This study investigates (1) how promising GP consider lifestyle changes to maintain cognitive performance in general, (2) GP beliefs about the power of modifiable health and lifestyle factors to maintain cognitive performance, and (3) whether those beliefs vary by GP age. METHODS: As part of the AgeWell.de trial, GPs (n = 72) completed a process evaluation questionnaire assessing their perspectives on lifestyle changes to preserve cognitive performance in elderly patients. In greater detail, their perceived efficacy of established risk and protective factors was investigated using a 5-point Likert scale. Descriptive statistical analyses were performed for research question (1) and (2). Spearman´s rank correlations and ordinal logistic regressions were used to answer research question (3). All results were interpreted exploratively. RESULTS: GPs rated the overall chance of lifestyle changes maintaining cognitive performance quite neutral with a median score of 3.0 (IQR = 2.0). They rated the efficacy of all the modifiable health and lifestyle factors high, with increase in physical and social activity ((Mdn = 5.0, IQR = 1.0) receiving the highest ratings with the narrowest range. Spearman's rank correlation indicated a significant positive relationship between age and the belief in "Optimization of nutrition" for preventing cognitive decline and dementia (ρ = .255, p = .041). However, ordinal logistic regressions showed no significant relationships between age and GP ratings of lifestyle change efficacy. CONCLUSION: These findings highlight the positive perception of GPs on the efficacy of modifiable health and lifestyle factors for preventing cognitive decline and dementia. TRIAL REGISTRATION: The AgeWell.de trial is registered in the German Clinical Trials Register (DRKS; trial identifier: DRKS00013555, Registration Date 07 December 2017).

Adherence to a lifestyle intervention - just a question of self-efficacy? Analysis of the AgeWell.de-intervention against cognitive decline.

BACKGROUND: Aim of this study was to detect predictors of better adherence to the AgeWell.de-intervention, a two-year randomized multi-domain lifestyle intervention against cognitive decline. METHODS: Data of 317 intervention group-participants comprising a risk group for dementia (Cardiovascular Risk Factors, Ageing and Dementia (CAIDE) score of ≥ 9; mean age 68.9 years, 49.5% women) from the AgeWell.de intervention study were analysed. Regression models with four blocks of predictors (sociodemographic, cognitive and psychosocial, lifestyle factors and chronic conditions) were run on adherence to the components of nutrition, enhancement of social and physical activity and cognitive training. Adherence to each component was operationalised by assessing the degree of goal achievement per component at up to seven time points during the intervention period, measured using a 5-point Likert scale (mean score of goal achievement). RESULTS: Increasing age was negatively associated with adherence, while higher education positively predicted adherence. Participants with better mental state (Montreal Cognitive Assessment (MoCA)-score > 25) at baseline and higher self-efficacy adhered better. Diabetes and cardiovascular conditions were not associated with adherence, whereas smoking negatively affected adherence. Highest education and quitting smoking in the past were the only predictors associated with all four intervention components. CONCLUSION: Results identified predictors for better and worse adherence. Particularly self-efficacy seems to be of considerable influence on adherence. This should be considered when designing future intervention trials. TRIAL REGISTRATION: German Clinical Trials Register (ref. number: DRKS00013555).

Living with Male Breast Cancer: A Qualitative Study of Men's Experiences and Care Needs.

BACKGROUND: Male breast cancer (MBC) is rare, and most previous studies limited their focus on clinical aspects of the disease. Psychosocial implications and care needs of MBC patients are poorly understood. OBJECTIVES: The aim of this study is to explore the experiences of men living with breast cancer and to identify supportive care needs. METHODS: Eighteen men were interviewed using qualitative, semi-structured telephone interviews. Qualitative content analysis was used to analyze the data. RESULTS: The majority of men did not have negative feelings about having a "women's disease," although some felt that stigmatization threatened their masculinity. Male sex was perceived as hindering access to adequate care. Patients identified key barriers including (1) a lack of awareness and experience of treating males among health professionals; (2) treatment and available information were based on evidence for females; and (3) lacking support services. CONCLUSION: To improve MBC care, it is important to raise awareness of the disease and to adapt treatment strategies, patient information, and support services to meet the needs of men.

Health behaviour, social support, socio-economic status and the 5-year progression of multimorbidity: Results from the MultiCare Cohort Study.

BACKGROUND: Multimorbidity in elderly patients is a major challenge for physicians, because of a high prevalence of and associations with many adverse outcomes. However, the mechanisms of progressing multimorbidity are not well-understood. The aim of our study was to determine if the progression of multimorbidity is influenced by health behaviour and social support and to analyse if the patients' socio-economic status had an effect on these prognostic factors. METHODS: The study was designed as prospective cohort study based on interviews of 158 GPs and 3189 patients randomly selected from GP records (response rate: 46.2%). Patients were aged 65-85 years at recruitment and observed in four waves of data collection (dropout rate: 41.5%). Statistical analyses of the 'hot deck' imputed data included multilevel mixed-effects linear regression allowing for random effects at the study centre and GP practice within study centre level. RESULTS: Regarding cardiovascular and metabolic diseases, multimorbidity progressed more rapidly in patients who reported less physical activity (ß = -0.28; 95% confidence interval = -0.35 to -0.20), had more tobacco-related pack years (0.15; 0.07-0.22) and consumed less alcohol (-0.21; -0.31 to -0.12) at baseline. Multimorbidity related to psychiatric and pain-related disorders progressed more rapidly if the patients had less perceived social support (-0.31; -0.55 to -0.07) and reported less physical activity (-0.08; -0.15 to -0.02) at baseline. Education and income only slightly modified the effects of these variables. CONCLUSION: Depending on the multimorbidity cluster, different strategies should be used for slowing down the progression of multimorbidity. Changing lifestyle and increasing social support are beneficial for the entire group of elderly multimorbid patients - regardless of their socio-economic status. REGISTRATION: ISRCTN89818205.

Narrative medicine-based intervention in primary care to reduce polypharmacy: results from the cluster-randomised controlled trial MultiCare AGENDA.

OBJECTIVES: To determine if patient-centred communication leads to a reduction of the number of medications taken without reducing health-related quality of life. DESIGN: Two-arm cluster-randomised controlled trial. SETTING: 55 primary care practices in Hamburg, Düsseldorf and Rostock, Germany. PARTICIPANTS: 604 patients 65 to 84 years of age with at least three chronic conditions. INTERVENTIONS: Within the 12-month intervention, general practitioners (GPs) had three 30 min talks with each of their patients in addition to routine consultations. The first talk aimed at identifying treatment targets and priorities of the patient. During the second talk, the medication taken by the patient was discussed based on a 'brown bag' review of all the medications the patient had at home. The third talk served to discuss goal attainment and future treatment targets. GPs in the control group performed care as usual. PRIMARY OUTCOME MEASURES: We assumed that the number of medications taken by the patient would be reduced by 1.5 substances in the intervention group and that the change in the intervention group's health-related quality of life would not be statistically significantly inferior to the control group. RESULTS: The patients took a mean of 7.0±3.5 medications at baseline and 6.8±3.5 medications at follow-up. There was no difference between treatment and control group in the change of the number of medications taken (0.43; 95% CI -0.07 to 0.93; P=0.094) and no difference in health-related quality of life (0.03; -0.02 to 0.08; P=0.207). The likelihood of receiving a new prescription for analgesics was twice as high in the intervention group compared with the control group (risk ratio, 2.043; P=0.019), but the days spent in hospital were reduced by the intervention (-3.07; -5.25 to -0.89; P=0.006). CONCLUSIONS: Intensifying the doctor-patient dialogue and discussing the patient's agenda and personal needs did not lead to a reduction of medication intake and did not alter health-related quality of life. TRIAL REGISTRATION NUMBER: ISRCTN46272088; Pre-results.

[Shortage of physicians in rural areas and in the public health service : A critical analysis of the evidence on the role of medical education and training]. / Ärztemangel in der hausärztlichen Versorgung auf dem Lande und im Öffentlichen Gesundheitsdienst : Eine kritische Analyse der Evidenz bezüglich der Rolle von Aus- und Weiterbildung.

BACKGROUND: A shortage of medical personnel has been seen for several decades in at least two sectors of the healthcare system: primary care in remote areas as well as medical care in the state public health departments (Öffentliches Gesundheitswesen). Strategies to reduce these problems are being sought. OBJECTIVE: This review examines the proposals, practical initiatives and empirical studies in under- and postgraduate medical education in order to estimate their potential impact on the solution of these problems. The analysis covers both Germany and Anglo-Saxon countries. MATERIALS AND METHODS: The study is based on a literature search in PubMed and Medline covering the last 20 years. With regard to Germany, programmatic documents and studies published in the German Journal of General Practice (Zeitschrift für Allgemeinmedizin) were also included. RESULTS AND DISCUSSION: Foreign empirical studies identify almost equal two factors with regard to primary care in remote areas: the recruitment of students from rural areas combined with special educational programs with a rural primary care orientation both in under- and postgraduate medical education. These programs should include several and longer practical working periods in primary care units and be well coordinated between the medical school and the local teaching physicians. As for the state public health sector, comparable initiatives are still lacking.

Is the Short Form of the Mini-Mental State Examination (MMSE) a better screening instrument for dementia in older primary care patients than the original MMSE? Results of the German study on ageing, cognition, and dementia in primary care patients (AgeCoDe).

The aim of the study was to investigate the psychometric properties of a Short Form of the Mini-Mental State Examination (SMMSE) for the screening of dementia in older primary care patients. Data were obtained from a large longitudinal cohort study of initially nondemented individuals recruited via primary care chart registries and followed at 18-month intervals. Item and scale parameters for MMSE and SMMSE scores were analyzed and cross-validated for 2 follow-up assessments (n1 = 2,657 and n2 = 2,274). Binary logistic regression and receiver-operating-characteristic (ROC) curve analyses were conducted in order to assess diagnostic accuracy parameters for MMSE and SMMSE scores. Cross-sectional differentiation between dementia-free and dementia patients yielded moderate to good results for MMSE and SMMSE scores. With regard to most diagnostic accuracy parameters, SMMSE scores did not outperform the MMSE scores. The current study provides first evidence regarding the psychometric properties of the SMMSE score in a sample of older primary care patients. However, our findings do not confirm previous findings that the SMMSE is a more accurate screening instrument for dementia than the original MMSE. Further studies are needed in order to assess and to develop short, reliable and valid instruments for routine cognitive screening in clinical practice and primary care settings.

[Diagnosing and diagnosis coding of dementias in claims data from German statutory health insurance]. / Diagnosestellung und Diagnosecodierung von Demenzen im Spiegel der Abrechnungsdaten der gesetzlichen Krankenversicherung.

OBJECTIVE: On the basis of data from one German Sickness Fund we analyzed which medical discipline coded the incident diagnosis of dementia in ambulatory medical care in Germany, which type of dementia was coded and how the initial code eventually changed during the year of incidence. METHODS: Claims data of 1,848 insured people aged ≥ 65 years in 2004 with incident dementia were analyzed by means of descriptive statistics. RESULTS: The diagnosis within the first quarter of the incidence year was coded by the GP in 71%, by a psychiatrist or neurologist in 14%, by both in 6% and by other disciplines in 9% of the cases. The percentage of unspecified diagnoses was 62% among GPs and 46% among psychiatrists or neurologists, a number differing largely from epidemiological studies. In 27% of the cases patients received two or more different dementia diagnoses during the incidence year. CONCLUSION: Studies and care concepts regarding dementia on the basis of diagnosis codes in ambulatory claims data should be interpreted with great caution.

[Size and type of frequent use of ambulatory medical care among the elderly population in Germany: a study based on statutory health insurance data]. / Umfang und Typologie der Häufignutzung in der vertragsärztlichen Versorgung der älteren Bevölkerung - Eine Analyse auf der Basis von GKV-Abrechnungsdaten.

BACKGROUND: The authors report the results of a study on frequent attenders in ambulatory medical care among elderly people in Germany and on the factors related to frequent attendance such as age, sex, multi-morbidity and long-term care dependency. METHODS: The study was based on claims data of all policy holders aged 65 and over of a statutory health insurance company operating nationwide in Germany in 2004 (n=123,224). Utilisation was analysed by the number of contacts with practices of physicians working in the ambulatory medical care sector and by the number of different practices contacted. The criteria for frequent attendance included greater than or equal to 50 contacts and/or greater than or equal to 10 different practices contacted and/or greater than or equal to 3 practices of the same discipline contacted within one year. Descriptive statistical analysis and logistic regression were used. RESULTS: 19% of the elderly were identified as frequent attenders, which corresponds to some 3.5 million people in Germany. Two main types of frequent attendance were identified: one is characterised by very many contacts, old age, frequent presence of multi-morbidity, and/or long-term care dependency. The other type is the younger, less frequently multi-morbid attender who is considerably less often dependent on long-term care, and characterised by large numbers of contacted practices and/or practices of the same discipline. CONCLUSION: Frequent attendance is due to several factors. The problem of frequent attendance needs further research that is not exclusively based on claims data. We found a high rate of frequent attendance. Further research should clarify if this is to the benefit of elderly people.

[Which chronic diseases are associated with frequent attending of ambulatory medical care in the elderly population in Germany? - A study based on statutory health insurance data]. / Mit welchen chronischen Krankheiten ist eine Häufignutzung der vertragsärztlichen Versorgung in der älteren Bevölkerung assoziiert? - Eine Analyse auf der Basis von GKV-Abrechnungsdaten.

BACKGROUND: Frequent attenders utilise a high proportion of medical services and therefore produce relatively high costs. Questions of utility and adequacy and, also, about the reasons for high use arise. The authors report the results of a study on the association between morbidity of the elderly and various forms of frequent attendance in ambulatory medical care in Germany. METHODS: The study is based on claims data of all policyholders aged 65 and over of a statutory health insurance company operating nationwide in Germany in 2004 (n = 123,224). Utilisation was analysed by the number of contacts with practices of physicians working in the ambulatory medical care sector and by the number of different practices contacted. Criteria for frequent attendance were ≥ 50 contacts with practices or contacts with ≥ 10 individual practices or ≥ 3 practices of the same discipline per year. We analysed prevalences and relative risks for frequent attendance for 46 chronic diseases. RESULTS: Frequent attendance in ambulatory medical care among the elderly is related to both severe somatic and psychic diagnoses. Five chronic diseases showed the highest relative risks for all types of frequent attendance in general: urinary incontinence, anaemia, neuropathies, renal insufficiency, and cancer. Psychic syndromes mainly led to the utilisation of many different physicians. CONCLUSION: Frequent attendance in ambulatory medical care among the elderly is related to a large number of diseases, both somatic and psychic. Frequent attendance is a complex phenomenon which cannot be addressed by mono-dimensional approaches.

Activating GENeral practitioners dialogue with patients on their Agenda (MultiCare AGENDA) study protocol for a cluster randomized controlled trial.

BACKGROUND: This study investigates the efficacy of a complex multifaceted intervention aiming at increasing the quality of care of GPs for patients with multimorbidity. In its core, the intervention aims at enhancing the doctor-patient-dialogue and identifying the patient's agenda and needs. Also, a medication check is embedded. Our primary hypothesis is that a more patient-centred communication will reduce the number of active pharmaceuticals taken without impairing the patients' quality of life. Secondary hypotheses include a better knowledge of GPs about their patients' medication, a higher patient satisfaction and a more effective and/or efficient health care utilization. METHODS/DESIGN: Multi-center, parallel group, cluster randomized controlled clinical trial in GP surgeries. INCLUSION CRITERIA: Patients aged 65-84 years with at least 3 chronic conditions. INTERVENTION: GPs allocated to this group will receive a multifaceted educational intervention on performing a narrative doctor-patient dialogue reflecting treatment targets and priorities of the patient and on performing a narrative patient-centred medication review. During the one year intervention GPs will have a total of three conversations à 30 minutes with the enrolled patients. CONTROL: Care as usual. Follow-up per patient: 14 months after baseline interview. Primary efficacy endpoints: Differences in medication intake and health related quality of life between baseline and follow-up in the intervention compared to the control group. Randomization: Computer-generated by an independent institute. It will be performed successively when patient recruitment in the respective surgery is finished. Blinding: Participants (GPs and patients) will not be blinded to their assignment but will be unaware of the study hypotheses or outcome measures. DISCUSSION: There is growing evidence that the phenomenon of polypharmacy and low quality of drug use is substantially due to mis-communication (or non-communication) in the doctor patient interaction. We assume that the number of pharmaceutical agents taken can be reduced by a communicational intervention and that this will not impair the patients' health-related quality of life. Improving communication is a core issue of future interventions, especially for patients with multimorbidity. TRIAL REGISTRATION: Current CONTROLled Trials ISRCTN46272088.

Motivational reserve: motivation-related occupational abilities and risk of mild cognitive impairment and Alzheimer disease.

Midlife motivational abilities, that is, skills to initiate and persevere in the implementation of goals, have been related to mental and physical health, but their association with risk of mild cognitive impairment (MCI) and Alzheimer's disease (AD) has not yet been directly investigated. This relation was examined with data from the German Study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe). A total of 3,327 nondemented participants (50.3% of a randomly selected sample) aged 75-89 years were recruited in primary care and followed up twice (after 1.5 and 3 years). Motivation-related occupational abilities were estimated on the basis of the main occupation (assessed at follow-up II) using the Occupational Information Network (O* NET) database, which provides detailed information on worker characteristics and abilities. Cox proportional hazards models were used to evaluate the relative risk of developing MCI and AD in relation to motivation-related occupational abilities, adjusting for various covariates. Over the 3 years of follow-up, 15.2% participants developed MCI and 3.0% developed AD. In a fully adjusted model, motivation-related occupational abilities were found to be associated with a reduced risk of MCI (HR: 0.77; 95% CI: 0.64-0.92). Motivation-related occupational abilities were associated with reduced risk of AD in ApoE ε4 carriers (HR: 0.48; CI: 0.25-0.91), but not in noncarriers (HR: 0.99; CI: 0.65-1.53). These results suggest that midlife motivational abilities are associated with reduced risk of MCI in general and with reduced risk of AD in ApoE ε4 carriers. Revealing the mechanisms underlying this association may inform novel prevention strategies for decelerating cognitive decline in old age.

Impact of geriatric comorbidity and polypharmacy on cholinesterase inhibitors prescribing in dementia.

BACKGROUND: Although most guidelines recommend the use of cholinesterase inhibitors (ChEIs) for mild to moderate Alzheimer's Disease, only a small proportion of affected patients receive these drugs. We aimed to study if geriatric comorbidity and polypharmacy influence the prescription of ChEIs in patients with dementia in Germany. METHODS: We used claims data of 1,848 incident patients with dementia aged 65 years and older. Inclusion criteria were first outpatient diagnoses for dementia in at least three of four consecutive quarters (incidence year). Our dependent variable was the prescription of at least one ChEI in the incidence year. Main independent variables were polypharmacy (defined as the number of prescribed medications categorized into quartiles) and measures of geriatric comorbidity (levels of care dependency and 14 symptom complexes characterizing geriatric patients). Data were analyzed by multivariate logistic regression. RESULTS: On average, patients were 78.7 years old (47.6% female) and received 9.7 different medications (interquartile range: 6-13). 44.4% were assigned to one of three care levels and virtually all patients (92.0%) had at least one symptom complex characterizing geriatric patients. 13.0% received at least one ChEI within the incidence year. Patients not assigned to the highest care level were more likely to receive a prescription (e.g., no level of care dependency vs. level 3: adjusted Odds Ratio [OR]: 5.35; 95% CI: 1.61-17.81). The chance decreased with increasing numbers of symptoms characterizing geriatric patients (e.g., 0 vs. 5+ geriatric complexes: OR: 4.23; 95% CI: 2.06-8.69). The overall number of prescribed medications had no influence on ChEI prescription and a significant effect of age could only be found in the univariate analysis. Living in a rural compared to an urban environment and contacts to neurologists or psychiatrists were associated with a significant increase in the likelihood of receiving ChEIs in the multivariate analysis. CONCLUSIONS: It seems that not age as such but the overall clinical condition of a patient including care dependency and geriatric comorbidities influences the process of decision making on prescription of ChEIs.

Antidementia drug prescription sources and patterns after the diagnosis of dementia in Germany: results of a claims data-based 1-year follow-up.

We examined the patterns of prescription for antidementia drugs by German physicians with special reference to source of prescription, appropriateness of drugs and dosages and continuity of prescription patterns. The study is based on claims data of all 1848 incident cases in persons aged 65 years and older from a nationwide operating statutory health insurance company in the years 2004-2006. Inclusion criteria were one International Statistical Classification of Diseases and Related Health Problems 10th Revision code for dementia in at least three of four consecutive quarters and four quarters without such a code beforehand. Defined daily doses were used to quantify the prescription size. Data analysis used univariate and multivariate techniques. The majority of incident dementia cases in general and Alzheimer's disease cases in particular did not receive medication in conformity with the guidelines during the year after incidence. Inappropriate prescription was related to not visiting a specialist, living in urban areas, age and comorbidity. Further research is needed both on reasons for nonprescription among professionals and for discontinuation by the patients. In addition, the problems of practicability and implementation of guidelines deserve more attention.

Selection effects may account for better outcomes of the German Disease Management Program for type 2 diabetes.

BACKGROUND: The nationwide German disease management program (DMP) for type 2 diabetes was introduced in 2003. Meanwhile, results from evaluation studies were published, but possible baseline differences between DMP and usual-care patients have not been examined. The objective of our study was therefore to find out if patient characteristics as socio-demographic variables, cardiovascular risk profile or motivation for life style changes influence the chance of being enrolled in the German DMP for type 2 diabetes and may therefore account for outcome differences between DMP and usual-care patients. METHODS: Case control study comparing DMP patients with usual-care patients at baseline and follow up; mean follow-up period of 36 ± 14 months. We used chart review data from 51 GP surgeries. Participants were 586 DMP and 250 usual-care patients with type 2 diabetes randomly selected by chart registry. Data were analysed by multivariate logistic and linear regression analyses. Significance levels were p ≤ 0.05. RESULTS: There was a better chance for enrolment if patients a) had a lower risk status for diabetes complications, i.e. non-smoking (odds ratio of 1.97, 95% confidence interval of 1.11 to 3.48) and lower systolic blood pressure (1.79 for 120 mmHg vs. 160 mmHg, 1.15 to 2.81); b) had higher activity rates, i.e. were practicing blood glucose self-monitoring (1.67, 1.03 to 2.76) and had been prescribed a diabetes patient education before enrolment (2.32, 1.29 to 4.19) c) were treated with oral medication (2.17, 1.35 to 3.49) and d) had a higher GP-rated motivation for diabetes education (4.55 for high motivation vs. low motivation, 2.21 to 9.36). CONCLUSIONS: At baseline, future DMP patients had a lower risk for diabetes complications, were treated more intensively and were more active and motivated in managing their disease than usual-care patients. This finding a) points to the problem that the German DMP may not reach the higher risk patients and b) selection bias may impair the assessment of differences in outcome quality between enrolled and usual-care patients. Suggestions for dealing with this bias in evaluation studies are being made.

Prevalence and risk factors for depression in non-demented primary care attenders aged 75 years and older.

BACKGROUND: Depression among the elderly is an important public health issue. The aims of this study were to report the prevalence of depression and to determine the impact of socio-demographic variables, functional impairment and medical diagnoses, lifestyle factors, and mild cognitive impairment on depression as part of the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe Study). METHODS: Included in the cross-sectional survey were 3327 non-demented subjects aged 75 and over attending general practitioners (GPs) (n=138) in an urban area of Germany. The GDS-15 Geriatric Depression Scale was used to measure depression with a threshold of <6/6+. Associations with social and clinical risk factors were assessed by means of multiple logistic regression models. RESULTS: The prevalence of depression was 9.7% (95% confidence interval 8.7-10.7). In a univariate analysis, the following variables were significantly associated with depression: female gender, increasing age, living alone, divorce, lower educational status, functional impairment, comorbid somatic disorder, mild cognitive impairment, smoking, and abstinence from alcohol. After full adjustment for confounding variables, odds ratios for depression were significantly higher only for functional impairment, smoking, and multi-domain mild cognitive impairment. LIMITATIONS: Recruitment procedures might have led to an underestimation of current prevalence. The cross-sectional data did not allow us to analyze the temporal relationship between risk factors and depression. CONCLUSIONS: The prevalence of depression in the elderly is high and remains high into old age. In designing prevention programs, it is important to call more attention to the impact of functional and cognitive impairment on depression.