Geriatric traumatology (e. g. "Alterstraumatologie") is more than orthogeriatrics-Experiences of a physician in advanced training.

This article reporting the view of an early career physician focuses on the diverse components of orthogeriatric co-management in a clinical setting. Geriatric trauma patients require a multimodal and interdisciplinary management, which includes individual and age-specific aspects, such as intensified physiotherapy, trauma surgery and geriatric expertise as well as social support. In Germany this surgical and geriatric co-treatment is provided by the program geriatric traumatology (Alterstraumatologie), which is implemented and certified at special institutions called geriatric trauma centers (Alters-Trauma-Zentrum). This special care is accomplished by an orthogeriatric co-management, which combines the efforts of both modern state of the art trauma surgery and geriatric medicine, preferable by using the procedure of the so-called geriatric early rehabilitative complex treatment (geriatrische frührehabilitative Komplexbehandlung) according to the diagnosis-related group (DRG) procedure OPS 8550. This is administered in 3 periods: the preoperative period, perioperative period and postoperative period and if indicated followed and completed by a geriatric rehabilitation. According to recent studies this approach has proved to be beneficial especially with respect to a reduction of posttraumatic morbidity rates and avoiding loss of function.

Effect of antithrombotic drugs on bone health.

With the increasing consumption of antithrombotic drugs among old people, expected as well as unexpected side effects on bone health are considerable, e.g. osteoporosis, fragility fractures, etc. This review focuses on antithrombotic drugs and their effects on bone health. The following groups were reviewed: parenteral long-term use of unfractionated heparin (UFH) is associated with osteopenia. The oral intake of vitamin K antagonists (VKA) makes them more convenient than UFH but chronic use also results in osteopenia. Limited reports of bone loss have been associated with low molecular weight heparins (LMWH) and indirect factor Xa inhibitors but in contrast to VKA and UFH they are less associated with osteopenia. There have been limited studies evaluating the effect of new oral anticoagulants (NOACs) on bones. Overall, they are considered safer than other drugs. There have been no reports about acetylsalicylic acid (ASA) and clopidogrel causing osteopenia but their metabolism by the kidneys and liver can cause reduced 25-hydroxy-vitamin D levels and can theoretically contribute to osteoporosis. Some reports suggested that high dosage clopidogrel can also negatively affect bones. After a detailed literature review long-term use of antithrombotic drugs can negatively affect the bones. Their role in bone health needs to be studied in detail and the clinical use in geriatric patients should be prudent.

[Development and validation of the Mini Dental Assessment : A procedure for improved estimation of need for dental treatment in geriatrics]. / Entwicklung und Validierung des "Mini Dental Assessment" : Ein Verfahren zur besseren Einschätzung des zahnärztlichen Behandlungsbedarfes in der Geriatrie.

BACKGROUND: In the future there will be an increasing demand for professional care with simultaneous retention of the dentition in older people. Due to inadequate dental knowledge, it is often not possible for caregivers to adequately assess dental deficits. OBJECTIVE: The aim of the study was to develop and validate a simple tool (Mini Dental Assessment, MDA) to assess possible dental treatment needs (DTN) of residential geriatric facilities by nursing personnel. MATERIAL AND METHODS: In the study 169 patients (51 from the University Hospital Giessen, 118 from the Bonifatius Hospital Lingen) underwent a dental examination. The dental status was evaluated based on the California Dental Association (CDA) criteria and the DTN determined. In addition, the time since the patients last visit to a dentist (TLVD) and denture age (DA) were documented and a chewing function test (carrot eating test, CET) was carried out. In a second study 155 patients were examined (115 from the University Hospital Giessen, 40 from the Bonifatius Hospital Lingen) corresponding to the reference sample and including a further chewing function test (after Schimmel und Slavicek) and questionnaires on quality of life (Oral Health Impact Profile (OHIP), Denatl Impact on Daily Living (DiDDL)). RESULTS: A total of 108 patients required dental treatment. The mean value (±SD) for the TLVD was 2.5 ± 3.8 years and 10.8 ± 8.9 years for the DA. There was a positive correlation (Spearman, P < 0.005) between the DTN and degree of comminution in the CET (3.4 ± 1.8 grade). Based on the results an assessment tool was developed using the variables CET, TLVD and DA weighted by the respective regression coefficients (10:3:1). The resulting mean total MDA score was 51.32 ± 28.14. A sensitivity/specificity analysis was conducted and a receiver operating characteristic (ROC) curve calculated (area under curve, AUC: 0.805; 95% CI: 0.738-0.873). The ROC curve from the follow-up study showed a good agreement with the ROC curve from the reference study (AUC 0.829, 95% CI: 0.751-0.907). CONCLUSION: Based on the results of the study it could be shown that the MDA is a suitable instrument for making a valid statement on the assessment of DTN of patients in long-term care facilities. The validation study revealed the validity of the MDA in its originally developed form and the addition of two further chewing function tests did not significantly improve the validity of the MDA. Overall, the MDA appears to be an appropriate tool to help nursing home personnel to assess the necessity for nursing home residents to visit a dentist.

Mini dental assessment: a simple screening test for non-dental staff.

OBJECTIVE: The objective of this study was to develop a simple tool for the assessment of possible dental treatment needs (DTN) for non-dental professionals (Mini Dental Assessment, MDA). To keep the assessment universal, we aimed to base it on the patient's history and a simple chewing efficiency test (CET) as the dental status is a known determinant for chewing efficiency. MATERIALS & METHODS: The assessment was developed using data from 169 patients from two sites (University Hospital Giessen, St. Bonifatius Hospital Lingen, both Germany). In all patients, a dental examination was performed, the denture status was evaluated (based on the California Dental Association criteria; CDA criteria), and the DTN was determined. In addition, the time since the patient's last visit to a dentist (TLVD) and denture age (DA) were assessed. Furthermore, a CET was carried out and the comminution score was determined (CETS). RESULTS: In total, 108 patients required dental treatment. The mean value (±SD) was 2.9 ± 0.9 score points for the DTN, 2.5 ± 3.8 years for the TLVD, and 10.8 ± 8.9 years for the DA. There was a significant correlation (Spearman, P < .05) between the DTN and degree of comminution (3.4 ± 1.8). Based on the results of the statistical analysis, the intended assessment tool was developed using the variables CETS, TLVD, and DA weighed by their respective regression coefficients (10:3:1). Subsequently, the resulting MDA score (51.32 ± 28.14) was calculated. A sensitivity/specificity analysis was conducted and a receiver operating characteristic curve was calculated (SPSS 17.0, area under curve 0.805; 95 % CI 0.738-0.873). CONCLUSION: It can be concluded that the dental status of elderly patients is reflected in the outcome of the MDA. However, ongoing validation is needed. TRIAL REGISTRATION: DRKS00003219.

[Geriatrics or geriatricization of medicine : Quo vadis geriatrics?] / Geriatrie oder Geriatrisierung der Medizin : Quo vadis Geriatrie?

This article examines the question whether and how geriatrics will change in the future and whether in view of the demographic changes the trend will go more in the direction of a further expansion of geriatrics or more towards a geriatricization of individual specialist medical fields. The different development of geriatrics in the individual Federal States can only be understood historically and is absolutely problematic against the background of the new hospital remuneration system. Geriatrics is a typical cross-sectional faculty and still has demarcation problems with other faculties but has also not yet clearly defined the core competence. This certainly includes the increasing acquisition of decentralized joint treatment concepts and geriatric counselling services in the future, in addition to the classical assessment instruments. Keywords in association with this are: traumatology and othopedics of the elderly, geriatric neurology and geriatric oncology. Interdisciplinary geriatric expertise is increasingly being requested. Outpatient structures have so far not been prioritized in geriatrics. An independent research is under construction and it is gratifying that academic interest in geriatrics seems to be increasing and new professorial chairs have been established. It is not possible to imagine our hospital without geriatrics; however, there is still a certain imbalance between the clearly increased number of geriatric hospital beds, the representation of geriatrics in large hospitals (e.g. specialized and maximum care hospitals and university clinics), the secure establishment in further education regulations and the lack of a uniform nationwide concept of geriatrics.

[Vitamin B12 deficiency in the elderly]. / Vitamin-B12-Mangel im Alter.

The prevalence of vitamin B12 deficiency increases with age. Patients with dementia and spouses of patients with dementia are at special risk for the development of vitamin B12 deficiency. In a normal diet this vitamin is present only in animal source foods; therefore, vegans frequently develop vitamin B12 deficiency if not using supplements or foods fortified with cobalamin. Apart from dementia, most of these manifestations are completely reversible under correct therapy; therefore it is crucial to identify and to treat even atypical presentations of vitamin B12 deficiency as early as possible. This article deals with the physiology and pathophysiology of vitamin B12 metabolism. A practice-oriented algorithm which also considers health economic aspects for a rational laboratory diagnosis of vitamin B12 deficiency is presented. In cases with severe neurological symptoms, therapy should be parenteral, especially initially. For parenteral treatment, hydroxocobalamin is the drug of choice.

[Acetylsalicylic acid non-responders after ischemic insult in geriatric patients]. / Acetylsalicylsäure-Nonresponder nach ischämischem Insult bei geriatrischen Patienten.

BACKGROUND: The cardiovascular and cerebral ischemic risk is defined as the risk of suffering a thromboembolic event. The common secondary prophylaxis is still the use of acetylsalicylic acid (ASA). The usual daily dose is 100 mg. Efficacy concerning platelet aggregation is not routinely checked. MATERIAL AND METHODS: In this study, patients taking 100 mg aspirin daily (orally) were examined after admittance to the stroke unit due to a stroke or stroke recurrence. Platelet aggregation was performed using a Platelet Function Analyser (PFA 100). RESULTS: A total of 71 patients were examined, 53(73%) had experienced a primary ischemic insult, and 18(25.4%) stroke recurrence. Patients with prolonged closure time in the collagen/epinephrine cell (normal range 85-165 s) were classified as responders to ASA, while 14 (19.7%) were classified as non-responders. CONCLUSION: It remains open whether the secondary prophylaxis or a more effective inhibition of platelet aggregation results in the improved protection against a future event.

[Ten years of early complex geriatric rehabilitation therapy in the DRG system]. / 10 Jahre geriatrische frührehabilitative Komplexbehandlung im DRG-System.

BACKGROUND: Geriatric medicine, as a specialized form of treatment for the elderly, is gaining in importance due to demographic changes. Especially important for geriatric medicine is combining acute care with the need to maintain functionality and participation. This includes prevention of dependency on structured care or chronic disability and handicap by means of rehabilitation. METHODS AND MATERIALS: Ten years ago, the German DRG system tried to incorporate procedures (e.g., "early rehabilitation in geriatric medicine") in the hospital reimbursement system. OPS 8-550.x, defined by structural quality, days of treatment, and number of therapeutic interventions, triggers 17 different geriatric DRGs, covering most of the fields of medicine. OPS 8-550.x had been revised continuously to give a clear structure to quality aspects of geriatric procedures. However, OPS 8-550.x is based on proven need of in-hospital treatment. In the last 10 years, no such definition has been produced taking aspects of the German hospital system into account as well as aspects of transparency and benefit in everyday work. RESULTS: The German DRG system covers just basic reimbursement aspects of geriatric medicine quite well; however, a practicable and patient-oriented definition of "hospital necessity" is still lacking, but is absolutely essential for proper compensation. A further problem concerning geriatric medicine reimbursement in the DRG system is due to the different structures of providing geriatric in-hospital care throughout Germany.

A novel approach for discovering human behavior patterns using unsupervised methods.

BACKGROUND: As is well known, elderly people gradually lose the ability of self-care. The decline can be reflected in changes in their daily life behavior. A solution to assess their health status is to design sensor-enhanced living environments to observe their behavior, in which unobtrusive sensors are usually used. With respect to information extraction from the dataset collected by means of these kinds of sensors, unsupervised methods have to be relied on for practical application. Under the assumption that human lifestyle is associated with health status, this study intends to propose a novel approach to discover behavior patterns using unsupervised methods. METHODS: To evaluate the feasibility of this approach it was applied to datasets collected in the GAL-NATARS study. The study is part of the Lower Saxony research network Design of Environments for Aging (GAL) and conducted in subjects' home environments. The subjects recruited in GAL-NATARS study are older people (age ≥ 70 years), who are discharged from hospital to live alone again at their homes after treatment of a femoral fracture. RESULTS: The change of lifestyle regularity is measured. By analyzing the correlation between the extracted information and medical assessment results of four subjects, two of them exhibited impressive association and the other two showed less association. CONCLUSIONS: The approach may provide complementary information for health assessment; however, the dominant relationship between the change of behavior patterns and the health status has to be shown and datasets from more subjects must be collected in future studies. LIMITATIONS: Merely environmental data were used and no wearable sensor for activity detection or vital parameter measurement is taken into account. Therefore, this cannot comprehensively reflect reality.

[The clinical importance of the critical view of safety in laparoscopic cholecystectomy]. / Die klinische Bedeutung des "critical view of safety" in der laparoskopischen Gallenblasenchirurgie.

BACKGROUND: Injury of the bile duct during cholecystectomy (CHE) is a severe complication. The critical view of safety (CVS) can help to reduce the frequency of this complication during laparoscopic CHE. So far, no scoring of CVS images with a grading system is available. METHOD: The CVS images of 534 patients with laparoscopic CHE could be structurally analyzed and assessed with marks from 1 (very good) to 5 (insufficient). The CVS mark was correlated with the perioperative course. Additionally, the perioperative course of patients after laparoscopic CHE with and without a CVS image was investigated. RESULTS: In 534 patients 1 or more CVS images could be analyzed. The average CVS mark was 1.9, whereby 280 patients (52.4%) had a 1, 126 patients (23.6%) a 2, 114 (21.3%) a 3 and 14 patients (2.6%) a 4 or 5. Younger patients with elective laparoscopic CHE had CVS images significantly more frequently (p ≤ 0.04). The statistical examination with Pearson's χ2-test and the F­test (ANOVA) showed a significant correlation between improving CVS marks and reduction of surgery time (p < 0.01) and the hospitalization time (p < 0.01). For senior physicians the quota of CVS images ranged from 71% to 92% and the average marks from 1.5 to 2.2. The marks for the CVS images were significantly better for female than male patients (1.8 vs. 2.1, p < 0.01). DISCUSSION: There was a relatively broad distribution of marks for CVS images. Injuries of the bile duct can be avoided with a high degree of certainty with marks 1­2 for the CVS image. The CVS is not always adequately visualized in laparoscopic CHE.

[The COVID-19 pandemic had significant impact on duration of surgery and hospitalization time for patients after cholecystectomy]. / Die Auswirkungen der COVID-19 Pandemie führten zu signifikanten Veränderungen der Operations- und Liegezeiten bei Patienten nach Cholezystektomie.

BACKGROUND: The COVID-19 pandemic made substantial changes in medical care necessary. The aims of this study were to find out what influence the pandemic had on the perioperative course in patients with cholecystectomy (CHE) and to highlight possible residual consequences. METHOD: From 1 July 2018 to 31 December 2021 a total of 735 patients with CHE were analyzed. Up to 21 March 2020 patients were assigned to the regular patient group (Reg, n = 430), patients after this date (first lockdown 22 March 2020) to the Cov19 patient group (Cov19, n = 305) and the 2 groups were compared. RESULTS: The average age of all patients was 59 years and 63% were women. The average length of hospitalization (KrVD, time period between surgery and discharge) was 4.4 days. The patient groups Reg and Cov19 did not differ with respect to age, gender or KrVD. The total number of CHEs carried out was reduced by 21.4% in the Cov19 group. This affected elective and emergency CHE to the same extent. The length of surgery significantly increased in the Cov19 group from 64 min (SD 34 min) to 71 min (SD 38 min). The number of short and long hospital stays (KrVD 2 or >4 days) significantly increased in the Cov19 group from 4 % to 20 % (short stay, p < 0.01) and from 23 % to 27 % (long stay, p < 0.01). This was particularly observed for patients >70 years old with an increase in long stays from 43 % to 56 % in the Cov19 group. CONCLUSION: The COVID-19 pandemic led to a clear reduction in CHE both for elective and emergency interventions. Furthermore, a significant lengthening of the surgery and hospitalization times could be observed for older patients. The residual consequences of the pandemic could be shortened hospitalization times after uncomplicated CHE and more interventional treatment procedures in complex cases.

[Geriatric medicine. Current status and perspectives for the future]. / Geriatrie. Aktuelle Bedeutung und Zukunftsperspektiven.

Geriatric medicine is one of the most rapidly growing medical subspecialties as a response to demographic changes seen in all western societies. One of the main problems of all aging populations is the increase in incidence and severity of comorbidities. Three epidemiological types of (co)morbidities can be identified: (1) Cardiac and vascular diseases including risk factors like diabetes mellitus, (2) malignancies of the elderly and (3) cognitive impairments defined as dementia. These epidemiologic-medical classes need different strategies. The first morbidity type is addressed by preventive medicine and modern therapy with great successes in recent years. In contrast, malignant diseases are continuously increasing in the elderly cohort, but a variety of new therapeutic measure shave turned some previously fatal disorders into chronic ones. In contrast, neither preventive nor therapeutic measures are available for dementia. Our response is better care and support, which demands specialized human resources that are becoming scarce. Better training of more individuals to care for elderly is a great challenge for our society.

[Myelopoiesis and bone marrow function in elderly tumor patients]. / Myelopoese und Knochenmarkfunktion des alten Tumorpatienten.

According to a model described by Balducci, the human myelopoietic stem cell reserve shows a shift from the reproductive to the proliferative pool corresponding to higher immunological demands resulting from the breakdown of infection defences. Every "hematopoietic stress," i.e., sepsis and/or cytoreductive chemotherapy, leads to a reduction of myelopoietic stem cells in the elderly in contrast to an increase in younger individuals. These changes are relevant starting at the age of 70 years and show a reduced compensation capacity in the aged organism. In addition, the function of the effector cells, i.e., the granulocytes and especially their phagocytic capacity, as well as the balance between stimulating and inhibiting cytokines are compromised. A significant influence on leukopenia and febrile septicemia has been shown for several comorbidities, especially chronic inflammation. The prophylactic use of myelopoietic growth factors is, therefore, recommended for the elderly when there is an expected risk for hematotoxicity grade III or IV. However, prognostic tests to predict the individual risk of hematotoxicity and septicemia are lacking.

[After inconspicuous elective laparoscopic cholecystectomy patients can be discharged without control of laboratory parameters]. / Patienten* nach unauffälliger elektiver laparoskopischer Cholezystektomie können ohne Laborwertkontrollen entlassen werden ­ Ergebnisse einer prospektiven Studie.

BACKGROUND: The importance of postoperative control of laboratory parameters after elective laparoscopic cholecystectomy (lap-CHE) is controversial. The aim of this prospective study was to find out whether patients can be safely discharged following an inconspicuous perioperative course after lap-CHE without control of the laboratory parameters. METHOD: All patients with a lap-CHE from September 2020 to March 2022 were screened and included in the study after providing informed consent. The course was followed in a structured way with a scoring system (value 3-15 points) and questionnaire. A score of ≤ 9 reflected an inconspicuous perioperative course. Approval was obtained from the ethics committee of Heidelberg University (S-026/2020). RESULTS: A total of 275 patients who underwent gall bladder surgery were documented of which 220 (80%) patients underwent an elective lap-CHE and 56 (25%) of the patients were included in the study. Of the patients 51 with a score of ≤ 9 were discharged without providing a blood sample. The average age of the patients was 50.8 years, the average duration of hospital stay was 2.6 days and 40 out of 51 (78.4%) patients could be postoperatively questioned. None of the patients suffered from relevant complications after being discharged. Out of 40 patients 27 (67.5) visited a general practitioner again postoperatively and 4 were readmitted as inpatients due to other operations and an endoscopic intervention. All patients were satisfied with the course of surgery. CONCLUSION: Patients with an inconspicuous course after elective lap-CHE (score ≤ 9 points) can be discharged without a postoperative control of laboratory parameters.

[Which patient needs controls of laboratory values after elective laparoscopic cholecystectomy?-Can a score help?] / Welcher Patient benötigt Laborwertkontrollen nach elektiver laparoskopischer Cholezystektomie? ­ Kann ein Score helfen?

BACKGROUND: Laparoscopic cholecystectomy is nearly exclusively carried out as an inpatient operation in Germany. The aim of the study was to evaluate for which patients postoperative laboratory control values are necessary. METHODS: This retrospective analysis included 100 patients who underwent elective laparoscopic cholecystectomy. A scoring and data collection sheet was developed, which enables a risk stratification. Using the scoring system patients can achieve between 3 and 15 points. RESULTS: In total 100 patients were included in the study. Of the patients 64 (group 1) had between 3 and 8 points, 29 patients (group 2) between 9 and 11 points and 7 patients (group 3) between 12 and 15 points. In comparison to group 1 the C­reactive protein values as well as the duration of hospital stay were significantly increased in group 2 and group 3 (p > 0.05). In group1 a total of 60 patients (93.7%) were discharged regularly on postoperative days 1-3. In group 2 there were 17 patients (58.6%) who could be discharged with unremarkable blood values and in group 3 there were 3 patients (42.8%). In the total collective hospital discharge without a laboratory control of blood values would have been justified in 80% of the patients. CONCLUSION: A postoperative control of laboratory blood values is not routinely necessary for patients after elective laparoscopic cholecystectomy with a score <9 points.