Surgical Reintervention Rates after Invasive Treatment for Lower Urinary Tract Symptoms due to Benign Prostatic Syndrome: A Comparative Study of More than 43,000 Patients with Long-Term Followup.

PURPOSE: No large-scale comparison of the 4 most established surgical approaches for lower urinary tract symptoms due to benign prostate obstruction in terms of long-term efficacy is available. We compared photoselective vaporization, laser enucleation and open simple prostatectomy to transurethral resection with regard to 5-year surgical reintervention rates. MATERIALS AND METHODS: A total of 43,041 male patients with lower urinary tract symptoms who underwent transurethral resection (34,526), photoselective vaporization (3,050), laser enucleation (1,814) or open simple prostatectomy (3,651) between 2011 and 2013 were identified in pseudonymized claims and core data of the German local health care funds and followed for 5 years. Surgical reinterventions for lower urinary tract symptoms, urethral stricture or bladder neck contracture were evaluated. Surgical approach was related to reintervention risk using the Kaplan-Meier method and Cox proportional hazards models. RESULTS: A total of 5,050 first reinterventions were performed within 5 years of primary surgery (Kaplan-Meier survival without reintervention: 87.5%, 95% CI 87.2%-87.8%). Photoselective vaporization carried an increased hazard of reintervention (HR 1.31, 95% CI 1.17-1.46, p <0.001) relative to transurethral resection, open simple prostatectomy carried a lower hazard (HR 0.43, 95% CI 0.37-0.50, p <0.001) and laser enucleation of the prostate did not differ significantly (HR 0.84, 95% CI 0.66-1.08, p=0.2). This pattern was more pronounced regarding reintervention for lower urinary tract symptom recurrence (photoselective vaporization: HR 1.52, 95% CI 1.35-1.72, p <0.001; laser enucleation of the prostate: HR 0.84, 95% CI 0.63-1.14, p=0.3; open simply prostatectomy: HR 0.38, 95% CI 0.31-0.46, p <0.001 relative to transurethral resection). CONCLUSIONS: Five-year reintervention rates of transurethral resection and laser enucleation did not differ significantly, while photoselective vaporization had a substantially higher rate. Open simple prostatectomy remains superior to transurethral resection with respect to long-term efficacy.

Low Hospital Volume Increases Re-Revision Rate Following Aseptic Revision Total Knee Arthroplasty: An Analysis of 23,644 Cases.

BACKGROUND: Along with rising numbers of primary total knee arthroplasty (TKA), the number of revision total knee arthroplasties (R-TKAs) has been increasing. R-TKA is a complex procedure requiring special instruments, implants, and surgical skills. Therefore it is likely that hospitals with more R-TKAs have more experience with this type of surgery and therefore fewer complications. The purpose of this study is to evaluate the relationship between hospital volume and re-revision rate following R-TKA. METHODS: Using nationwide healthcare insurance data for inpatient hospital treatment, 23,644 aseptic R-TKAs in 21,573 patients treated between January 2013 and December 2017 were analyzed. Outcomes were 90-day mortality, 1-year re-revision rate, and in-house adverse events. The effect of hospital volumes on outcomes were analyzed by means of multivariate logistic regression. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Hospital volume had a significant effect on 1-year re-revision rate (≤12 R-TKA/a: OR 1.44, CI 1.20-1.72; 13-24 R-TKA/a: OR 1.43, CI 1.20-1.71; 25-52 R-TKA/a: OR 1.13, CI 0.94-1.35; ≥53 R-TKA/a: reference). Ninety-day mortality and major in-house adverse events decreased with increasing volume per year, but after risk adjustment this was not statistically significant. CONCLUSION: We found evidence of higher risk for re-revision surgery in hospitals with fewer than 25 R-TKA per year. It might contribute to improved patient care if complex elective procedures like R-TKA which require experience and a specific logistic background were performed in specialized centers.

Low Hospital Volume Increases Revision Rate and Mortality Following Revision Total Hip Arthroplasty: An Analysis of 17,773 Cases.

BACKGROUND: With the number of primary total hip arthroplasty (THA), the amount of revision THA (R-THA) increases. R-THA is a complex procedure requiring special instruments, implants, and surgical skills. Therefore it is likely that hospitals performing a higher number of R-THAs have more experience with this type of surgery and therefore fewer complications. The purpose of this study was to evaluate the relationship between hospital volume and risk of postoperative complications following R-THA. METHODS: Using nationwide healthcare insurance data for inpatient hospital treatment, 17,773 aseptic R-THAs in 16,376 patients treated between January 2014 and December 2016 were included. Outcomes were 90-day mortality, 1-year revision procedures, and in-house adverse events. The effect of hospital volume on outcome was analyzed by means of multivariate logistic regression. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. RESULTS: Hospital volume had a significant effect on 90-day mortality (≤12 cases per year: OR 2.13, CI 1.53-2.96; 13-24: OR 1.79, CI 1.29-2.50; 25-52: OR 1.53, CI 1.11-2.10; ≥53: reference) and 1-year revision procedures (≤12: OR 1.26, CI 1.09-1.47; 13-24: OR 1.18, CI 1.02-1.37; 25-52: OR 1.03, CI 0.90-1.19; ≥53: reference). There was no significant effect on risk-adjusted major in-house adverse events. CONCLUSION: We found evidence of higher risk for revision surgery and mortality in hospitals with fewer than 25 and 53 R-THA per year, respectively. To improve patient care, complex elective procedures like R-THA which require experience and a specific logistic background should be performed in specialized centers.

National trends and differences in morbidity among surgical approaches for radical prostatectomy in Germany.

OBJECTIVE: In this study, we document trends in radical prostatectomy (RP) employment in Germany during the period 2005-2012 and compare the morbidity of open (ORP), laparoscopic and robotic-assisted RP based on nationwide administrative data of Allgemeine Ortskrankenkassen (AOK) German local healthcare funds. MATERIALS AND METHODS: Administrative claims data of all AOK patients subjected to RP during 2005-2012 (57,156 cases) were used to evaluate the employment of minimally invasive RP (MIRP) procedures, pelvic lymph node dissection (PLND) and nerve-sparing approaches during this period. In addition, data from the most recent three-year period of our dataset (2010-2012) were used to compare the morbidity among the different surgical approaches. Study end points comprised 30-day mortality, 30-day transfusion, 1-year reintervention and 30-day adverse events, as well as 1-year overall complications. RESULTS: A 20 % reduction in RP utilization from 2007 to 2012 was documented. ORP remained the predominant RP approach in Germany. MIRP approaches carried a lower risk of 30-day transfusions, 1-year reinterventions and 1-year overall complications than ORP when adjusting for confounding factors. PLND was associated with an increased risk of complications, while age in the highest quintile and the presence of comorbidities were independent risk factors for morbidity and mortality. Lack of pathological data was the main limitation of the study. CONCLUSIONS: RP utilization in Germany is dropping, but the use of MIRP has risen steadily during the years 2005-2012, which is expected to have a positive impact on the morbidity of the operation.

Direct costs associated with depressive symptoms in late life: a 4.5-year prospective study.

BACKGROUND: Depression in old age is common. Only few studies examined the association of depressive symptoms and direct costs in the elderly in a cross-sectional way. This study aims to investigate prospectively health service use and direct costs over a course of 4.5 years considering also different courses of depressive symptomatology. METHODS: 305 primary care patients aged 75+ were assessed face-to-face regarding depressive symptoms (Geriatric Depression Scale), and service use and costs at baseline and 4.5 years later. Resource utilization was monetarily valued using 2004/2005 prices. The association of baseline factors and direct costs after 4.5 years was analyzed by multivariate linear regression. RESULTS: Mean annual direct costs of depressed individuals at baseline and follow-up were almost one-third higher than of non-depressed, and highest for individuals with chronic depressive symptoms. Most relevant cost drivers were costs for inpatient care, pharmaceuticals, and home care. Costs for home care increased at most in individuals with chronic depressive symptoms. Baseline variables that were associated with direct costs after 4.5 years were number of medications as a measure of comorbidity, age, gender, and depressive symptoms. CONCLUSIONS: Presence and persistence of depressive symptoms in old age seems to be associated with future direct costs even after adjustment for comorbidity. The findings deign a look to the potential economic consequences of depressive symptoms in the elderly for the healthcare system in the future.

Effects of multiple chronic conditions on health care costs: an analysis based on an advanced tree-based regression model.

BACKGROUND: To analyze the impact of multimorbidity (MM) on health care costs taking into account data heterogeneity. METHODS: Data come from a multicenter prospective cohort study of 1,050 randomly selected primary care patients aged 65 to 85 years suffering from MM in Germany. MM was defined as co-occurrence of ≥3 conditions from a list of 29 chronic diseases. A conditional inference tree (CTREE) algorithm was used to detect the underlying structure and most influential variables on costs of inpatient care, outpatient care, medications as well as formal and informal nursing care. RESULTS: Irrespective of the number and combination of co-morbidities, a limited number of factors influential on costs were detected. Parkinson's disease (PD) and cardiac insufficiency (CI) were the most influential variables for total costs. Compared to patients not suffering from any of the two conditions, PD increases predicted mean total costs 3.5-fold to approximately € 11,000 per 6 months, and CI two-fold to approximately € 6,100. The high total costs of PD are largely due to costs of nursing care. Costs of inpatient care were significantly influenced by cerebral ischemia/chronic stroke, whereas medication costs were associated with COPD, insomnia, PD and Diabetes. Except for costs of nursing care, socio-demographic variables did not significantly influence costs. CONCLUSIONS: Irrespective of any combination and number of co-occurring diseases, PD and CI appear to be most influential on total health care costs in elderly patients with MM, and only a limited number of factors significantly influenced cost. TRIAL REGISTRATION: Current Controlled Trials ISRCTN89818205.

Prediction of incident dementia: impact of impairment in instrumental activities of daily living and mild cognitive impairment-results from the German study on ageing, cognition, and dementia in primary care patients.

OBJECTIVES: There is an increasing call for a stronger consideration of impairment in instrumental activities of daily living (IADL) in the diagnostic criteria of Mild Cognitive Impairment (MCI) to improve the prediction of dementia. Thus, the aim of the study was to determine the predictive capability of MCI and IADL impairment for incident dementia. DESIGN: Longitudinal cohort study with four assessments at 1.5-year intervals over a period of 4.5 years. SETTING: : Primary care medical record registry sample. PARTICIPANTS: As part of the German Study on Ageing, Cognition, and Dementia in Primary Care Patients, a sample of 3,327 patients from general practitioners, aged 75 years and older, was assessed. MEASUREMENTS: The predictive capability of MCI and IADL impairment for incident dementia was analysed using receiver operating characteristics, Kaplan-Meier survival analyses, and Cox proportional hazards models. RESULTS: MCI and IADL impairment were found to be significantly associated with higher conversion to, shorter time to, and better predictive power for future dementia. Regarding IADL, a significant impact was particularly found for impairment in responsibility for one's own medication, shopping, and housekeeping, and in the ability to use public transport. CONCLUSIONS: Combining MCI with IADL impairment significantly improves the prediction of future dementia. Even though information on a set of risk factors is required to achieve a predictive accuracy for dementia in subjects with MCI being clinically useful, IADL impairment should be a very important element of such a risk factor set.

Predictors of institutionalisation in incident dementia--results of the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe study).

BACKGROUND/AIMS: In the past few decades, a number of studies investigated risk factors of nursing home placement (NHP) in dementia patients. The aim of the study was to investigate risk factors of NHP in incident dementia cases, considering characteristics at the time of the dementia diagnosis. METHODS: 254 incident dementia cases from a German general practice sample aged 75 years and older which were assessed every 1.5 years over 4 waves were included. A Cox proportional hazard regression model was used to determine predictors of NHP. Kaplan-Meier survival curves were used to evaluate the time until NHP. RESULTS: Of the 254 incident dementia cases, 77 (30%) were institutionalised over the study course. The mean time until NHP was 4.1 years. Significant characteristics of NHP at the time of the dementia diagnosis were marital status (being single or widowed), higher severity of cognitive impairment and mobility impairment. CONCLUSION: Marital status seems to play a decisive role in NHP. Early initiation of support of sufferers may ensure remaining in the familiar surroundings as long as possible.

The assessment of changes in cognitive functioning in the elderly: age- and education-specific reliable change indices for the SIDAM.

BACKGROUND/AIMS: The diagnostic criteria for dementia include reliable evidence of cognitive deterioration over time measured by cognitive tests. The Structured Interview for the Diagnosis of Dementia of the Alzheimer Type, Multi-infarct Dementia and Dementia of other Etiology according to DSM-III-R, DSM-IV and ICD-10 (SIDAM) is a neuropsychological instrument to determine cognitive status in patients with mild cognitive impairment (MCI) and dementia. Normative data for changes in cognitive functioning that normally occur in cognitively healthy individuals are required to interpret changes in SIDAM test scores. METHODS: A sample of 1,090 cognitively healthy individuals participating in the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe) aged 75 years and older was assessed four times at 1.5-year intervals over a period of 4.5 years using the SIDAM. Age- and education-specific reliable change indices (RCIs) accounting for probable measurement error and practice effects were computed for a 90% confidence interval. RESULTS: Across different age and education subgroups, changes from at least 3-5 points indicated significant (i.e. reliable) changes in SIDAM test scores at the 90% confidence level. CONCLUSION: This study offers age- and education-specific normative data for the SIDAM based upon established RCI methods. The RCI scores provided in this study may help clinicians and researchers to interpret cognitive changes in SIDAM test scores and may contribute to the early detection and diagnosis of MCI and dementia in the elderly.

Influence of social support on cognitive change and mortality in old age: results from the prospective multicentre cohort study AgeCoDe.

BACKGROUND: Social support has been suggested to positively influence cognition and mortality in old age. However, this suggestion has been questioned due to inconsistent operationalisations of social support among studies and the small number of longitudinal studies available. This study aims to investigate the influence of perceived social support, understood as the emotional component of social support, on cognition and mortality in old age as part of a prospective longitudinal multicentre study in Germany. METHODS: A national subsample of 2,367 primary care patients was assessed twice over an observation period of 18 months regarding the influence of social support on cognitive function and mortality. Perceived social support was assessed using the 14-item version of the FSozU, which is a standardised and validated questionnaire of social support. Cognition was tested by the neuropsychological test battery of the Structured Interview for the Diagnosis of Dementia (SIDAM). The influence of perceived support on cognitive change was analysed by multivariate ANCOVA; mortality was analysed by multivariate logistic and cox regression. RESULTS: Sample cognitive change (N = 1,869): Mean age was 82.4 years (SD 3.3) at the beginning of the observation period, 65.9% were female, mean cognition was 49 (SD 4.4) in the SIDAM. Over the observation period cognitive function declined in 47.2% by a mean of 3.4 points. Sample mortality (N = 2,367): Mean age was 82.5 years (SD 3.4), 65.7% were female and 185 patients died during the observation period. Perceived social support showed no longitudinal association with cognitive change (F = 2.235; p = 0.135) and mortality (p = 0.332; CI 0.829-1.743). CONCLUSIONS: Perceived social support did not influence cognition and mortality over an 18 months observation period. However, previous studies using different operationalisations of social support and longer observation periods indicate that such an influence may exist. This influence is rather small and the result of complex interaction mechanisms between different components of social support; the emotional component seems to have no or only a limited effect. Further research is needed to describe the complex interactions between components of social support. Longer observation periods are necessary and standardised operationalisations of social support should be applied.

Blood transfusion and venous thromboembolism trends and risk factors in primary and aseptic revision total hip and knee arthroplasties: A nationwide investigation of 736,061 cases.

BACKGROUND: Over the last years, new transfusion guidelines and pharmaceuticals have been introduced in primary and revision total hip and knee arthroplasty (P-THA, P-TKA, R-THA, R-TKA). In the US, a substantial decrease in transfusions has been observed in recent years. Little data exists on the subject in Europe. In this context we aimed to analyze: (1) Is there also a significant decrease in blood transfusion for these procedures in Germany? (2) Which patient and hospital related factors are associated with the risk of blood transfusion? (3) Is there a trend in complications, especially venous thromboembolism and stroke events that can be linked to tranexamic acid use? HYPOTHESIS: There is a significant trend in decreasing blood transfusions in hip and knee arthroplasty. METHODS: Using nationwide healthcare insurance data for inpatient hospital treatment, 736,061 cases treated between January 2011 and December 2017 were included (318,997 P-THAs, 43,780 R-THAs, 338,641 P-TKAs, 34,643 R-TKAs). Multivariable logistic regression was used to model the odds of transfusion as a function of the year of surgery. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: In each cohort the odds of transfusion decreased over time (2017 vs. 2011 (reference): P-THA: OR 0.42 (95%CI: 0.39-0.45), P-TKA: OR 0.41 (95%CI: 0.37-0.46), R-THA: OR 0.52 (95%CI: 0.47-0.58), R-TKA: OR 0.53 (95%CI: 0.46-0.61). Patient-related risk factors for blood transfusion included older age, female gender, lower Body Mass Index, comorbidities such as renal failure, cardiac arrhythmia, congestive heart failure, valvular disease, coagulopathy, depression, and antithrombotic medication prior to surgery. Venous thromboembolism or stroke events did not increase over the study period. DISCUSSION: The incidence of blood transfusions in primary and revision TKA and THA decreased over the study period. This may be due to new transfusion guidelines and the introduction of novel pharmaceuticals such as tranexamic acid. A further improved patient blood management and a focus on vulnerable patient groups might lead to a further future reduction of transfusions, especially in R-THA. LEVEL OF EVIDENCE: III; comparative observational study.

Malperformance in verbal fluency and delayed recall as cognitive risk factors for impairment in instrumental activities of daily living.

BACKGROUND: Maintaining independence in instrumental activities of daily living (IADL) is crucial for older adults. This study explored the association between cognitive and functional performance in general and in single IADL domains. Also, risk factors for developing IADL impairment were assessed. METHODS: Here, 3,215 patients aged 75-98 years were included. Data were collected during home visits. RESULTS: Cognitive functioning was associated with IADL both cross-sectionally and longitudinally. Regarding the single IADL domains cross-sectionally, executive functioning was especially associated with shopping, while episodic memory was associated with responsibility for own medication. CONCLUSION: Reduced performance in neuropsychological tests is associated with a greater risk of current and subsequent functional impairment.

Time to Surgery and Outcome in the Treatment of Proximal Femoral Fractures.

BACKGROUND: It has not been conclusively established whether, or to what extent, the time to surgery affects mortality and the risk of complications after the surgical treatment of proximal femoral fractures. METHODS: Data on 106 187 hospitalizations over the period 2015-2017 involving insurees of the German AOK health insurance company aged 20 and above were drawn from pseudonymized billing data and stratified in three subgroups: osteosynthesis for pertrochanteric fracture (PTF-OS: N = 52 358), osteosynthesis for femoral neck fracture (FNF-OS: N = 7970), and endoprosthesis for femoral neck fracture (FNF-EP: N = 45 859). Multivariate regression models were used to analyze the relation between preoperative in-hospital stay (time to surgery, TTS: 0 days [reference category], 1, 2, 3, 4-7 days) and mortality and general complications within 90 days, with risk adjustment for fracture site, operative method, age, sex, accompanying illnesses, and antithrombotic medication in the preceding year. RESULTS: Mortality was significantly elevated only with PTF-OS, and only with a TTS of 2 days (odds ratio: 1.12 [95% confidence interval: (1.02; 1.23)]). General complications in relation to TTS were significantly elevated in the following situations: PTF-OS: 2 days: OR 1.24 [1.13; 1.37], 3 days: OR 1.33 [1.11; 1.60], 4-7 days: OR 1.47 [1.21; 1.78]; FNF-EP: 3 days: OR 1.21 [1.06; 1.37], 4-7 days: OR 1.42 [1.25; 1.62]; FNF-OS: 4-7 days: OR 1.86 [1.26; 2.73]. CONCLUSION: A prolonged time to surgery is associated with an elevated general complication risk depending on the site of the fracture and the type of surgical procedure used.

Anosognosia in Alzheimer's disease: the role of impairment levels in assessment of insight across domains.

Impaired insight for deficits (anosognosia) is common in Alzheimer's disease (AD). However, it has not yet been determined clearly (a) whether different methods for assessing insight are comparable, and (b) whether anosognosia affects different domains to different degrees (domain-specificity). Impaired insight was investigated in 32 patients with AD, who were each accompanied by a caregiver. Anosognosia was assessed by a global clinical rating, questionnaire discrepancies (patient vs. caregiver) covering different domains, and performance discrepancies (self-assessment vs. performance) based on four neuropsychological tests which were compared with those of a healthy control sample. The results of clinical rating and questionnaire discrepancies were closely correlated, but performance discrepancies showed no association with the other methods. Anosognosia was present in the majority of the sample, and occurred across domains. The domains corresponding to core deficits in AD (recent memory, activities of daily living) appeared especially prone to anosognosia. However, results do not suggest that anosognosia itself is domain-specific. Rather, it appears that insight may be invariant, while differences in patient-caregiver discrepancies arise largely from different degrees of deficit across domains.

The costs of dementia from the societal perspective: is care provided in the community really cheaper than nursing home care?

OBJECTIVE: To compare the costs of care for community-dwelling dementia patients with the costs of care for dementia patients living in nursing homes from the societal perspective. DESIGN: Cross-sectional bottom-up cost of illness study nested within the multicenter German AgeCoDe-cohort. SETTING: Community and nursing homes. PARTICIPANTS: One hundred twenty-eight community-dwelling dementia patients and 48 dementia patients living in nursing homes. INTERVENTION: None. MEASUREMENTS: Utilization and costs of medical care and long term care, including formal and informal social and nursing care based on proxy interviews. Informal care was valued using the replacement cost method. RESULTS: Unadjusted mean annual total costs including informal care were €29,930 ($43,997) for community-dwelling patients and €33,482 ($49,218) for patients living in nursing homes. However, multiple regression analysis controlling for age, sex, deficits in basic and instrumental activities of daily living and comorbidity showed that living in the community significantly increased total costs by €11,344 ($16,676; P < .01) compared with living in a nursing home, mainly due to higher costs of informal care (+€20,585; +$30,260; P < .001). CONCLUSION: From the societal perspective care for dementia patients living in the community tends to cost more than care in nursing homes when functional impairment is controlled for.

A comparative study demonstrated that prevalence figures on multimorbidity require cautious interpretation when drawn from a single database.

OBJECTIVE: We investigated the degree of comparability of the prevalence of chronic diseases and disease combinations in the elderly in two databases comparable with regard to diseases included, sex and age of the patients (65-85 years), and cutoff score for case definition. STUDY DESIGN AND SETTING: One study is based on chart-supported interviews with the primary care physicians within a cohort study of 3,189 multimorbid elderly patients. The second study analyzed claims data from ambulatory care delivered to the multimorbid members of one German Health Insurance (n = 70,031). Multimorbidity was defined by the presence of three or more chronic conditions from an identical list of 46 diseases. RESULTS: The difference of the median number of chronic conditions was 1 (mean 6.7 vs. 5.7). The prevalences of individual conditions were approximately one-third lower in the claims data, but the relative rank order corresponded well between the two databases. These relatively small prevalence differences cumulate when combinations of chronic conditions are investigated, for example, the prevalence differences between the two databases increased to nearly 100% for triadic combinations and nearly 170% for quartets. CONCLUSION: The study shows that conclusions regarding the prevalence of combinations of diseases should be drawn with caution when based on a single database.

Predictors of costs in dementia in a longitudinal perspective.

OBJECTIVE: To analyse predictors of costs in dementia from a societal perspective in a longitudinal setting. METHOD: Healthcare resource use and costs were assessed retrospectively using a questionnaire in four waves at 6-month intervals in a sample of dementia patients (N = 175). Sociodemographic data, dementia severity and comorbidity at baseline, cognitive impairment and impairment in basic and instrumental activities of daily living were also recorded. Linear mixed regression models with random intercepts for individuals were used to analyse predictors of total and sector-specific costs. RESULTS: Impairment in activities of daily living significantly predicted total costs in dementia patients, with associations between basic activities of daily living and formal care costs on the one and instrumental activities of daily living and informal care costs on the other hand. Nursing home residence was associated with lower total costs than residence in the community. There was no effect of cognition on total or sector-specific costs. CONCLUSION: Cognitive deficits in dementia are associated with costs only via their effect on the patients' capacity for activities of daily living. Transition into a nursing home may reduce total costs from a societal perspective, owing to the fact that a high amount of informal care required by severely demented patients prior to transition into a nursing home may cause higher costs than inpatient nursing care.

Relative impact of multimorbid chronic conditions on health-related quality of life--results from the MultiCare Cohort Study.

BACKGROUND: Multimorbidity has a negative impact on health-related quality of life (HRQL). Previous studies included only a limited number of conditions. In this study, we analyse the impact of a large number of conditions on HRQL in multimorbid patients without preselecting particular diseases. We also explore the effects of these conditions on the specific dimensions of HRQL. MATERIALS AND METHODS: This analysis is based on a multicenter, prospective cohort study of 3189 multimorbid primary care patients aged 65 to 85. The impact of 45 conditions on HRQL was analysed. The severity of the conditions was rated. The EQ-5D, consisting of 5 dimensions and a visual-analogue-scale (EQ VAS), was employed. Data were analysed using multiple ordinary least squares and multiple logistic regressions. Multimorbidity measured by a weighted count score was significantly associated with lower overall HRQL (EQ VAS), b = -1.02 (SE: 0.06). Parkinson's disease had the most pronounced negative effect on overall HRQL (EQ VAS), b = -12.29 (SE: 2.18), followed by rheumatism, depression, and obesity. With regard to the individual EQ-5D dimensions, depression (OR = 1.39 to 3.3) and obesity (OR = 1.44 to 1.95) affected all five dimensions of the EQ-5D negatively except for the dimension anxiety/depression. Obesity had a positive effect on this dimension, OR = 0.78 (SE: 0.07). The dimensions "self-care", OR = 4.52 (SE: 1.37) and "usual activities", OR = 3.59 (SE: 1.0), were most strongly affected by Parkinson's disease. As a limitation our sample may only represent patients with at most moderate disease severity. CONCLUSIONS: The overall HRQL of multimorbid patients decreases with an increasing count and severity of conditions. Parkinson's disease, depression and obesity have the strongest impact on HRQL. Further studies should address the impact of disease combinations which require very large sample sizes as well as advanced statistical methods.

Effect of cardiovascular and metabolic disease on cognitive test performance and cognitive change in older adults.

OBJECTIVES: To examine the effect of cardiovascular and metabolic diseases on initial cognitive test performance and rate of change in three cognitive measures. DESIGN: Prospective cohort study. SETTING: General practices in six towns throughout Germany. PARTICIPANTS: Three thousand three hundred twenty-seven participants aged 75 and older (average 79.7 ± 3.6). MEASUREMENTS: Data were collected during home visits every 18 months and included sociodemographic variables, depression, disease status, drug intake, and cognition. RESULTS: Although the presence of transient ischemic attack (TIA) or stroke and diabetes mellitus was related to poor initial cognitive test performance, the presence of those and other far-reaching chronic diseases or a higher disease burden were not related to the rate of change in cognition over time. CONCLUSION: Diabetes mellitus, stroke and TIA affect cognitive test performance beyond well-known sociodemographic variables and depressive symptoms, although none of these diseases contributed to cognitive decline over time. In practical terms, prevention and diagnosis of cardiovascular and metabolic diseases may be essential to cognitively healthy aging.