Characterization of patients admitted to specialized geriatric acute care hospital units with the German version of the Standardized Evaluation and Intervention for Seniors at Risk (SEISAR) screening-instrument: a cross-sectional study.

BACKGROUND: The Standardized Evaluation and Intervention for Seniors at Risk (SEISAR) screening tool records major geriatric problems, originally applied in the emergency department. Particularly, the distinction of compensated and uncompensated problems is an interesting and new approach. Therefore, we translated the SEISAR in German language and used it to characterize patients in specialized geriatric hospital wards in Germany and to gather initial experience regarding its usability and practicability. METHODS: The tool was translated by three independent specialists in geriatric medicine and backtranslated for quality-assurance by a non-medical English native speaker. In a second step, 8 acute care geriatric hospital departments used the translated version to characterize all consecutive patients admitted over a period of one month between December 2019 and May 2020 at time of admission. RESULTS: Most of the 756 patients (78%) lived in an own apartment or house prior to hospital admission. Participants had on average 4 compensated and 6 uncompensated problems, a Barthel-Index of 40 pts. on admission with a median increase of 15 points during hospital stay, and a median length of stay of 16 days in the geriatric hospital department. CONCLUSION: SEISAR is an interesting standardized brief comprehensive geriatric assessment tool for the identification of compensated and uncompensated health problems in older persons. The data of this study highlights the number, variability, and complexity of geriatric problems in patients treated in specialized acute care geriatric hospital wards in Germany. TRIAL REGISTRATION: German Clinical trial register (DRKS-ID: DRKS00031354 on 27.02.2023).

[Urine retention-From the symptom to the structure]. / Harnverhalt ­ vom Symptom zur Struktur.

Urinary retention describes the inability to urinate. Based on the symptoms and the amount of the initial residual urine formation, a differentiation can be made between acute and chronic forms. The cause can be a subvesical obstruction or a bladder atony. In addition to emergency treatment in the form of initial relief of the strain on the bladder by insertion of a catheter, the indication for a definitive treatment with a clarification of the question whether an acute or chronic event is present is also important. Although the selection of the catheter is subject to few criteria, the further structured approach is complex. Both decision trees are presented in this article.

Reliability of the blood pressure response during performance of bedside Valsalva maneuver and association with NT-pBNP levels.

BACKGROUND: Heart failure (HF) is common in older people. The diagnosis of HF, however, is difficult in older subjects, especially in settings without direct access to further diagnostics. The type of blood pressure response during the performance of a Valsalva maneuver has been suggested as an easily applicable bedside test to detect HF; however, the reliability of this maneuver and the association with HF is unknown in geriatric patients. METHODS: This study included 89 patients admitted for geriatric rehabilitation. Systolic blood pressure was taken while the patient performed a Valsalva maneuver. The systolic blood pressure response was classified as sinusoidal (type A), absent overshoot (type B) or square pattern (type C). To test interrater reliability systolic blood pressure response was evaluated independently by two investigators. The procedure was repeated after 1h to estimate test-retest reliability. Both investigators were blinded to the results of the other. Interrater reliability and test-retest reliability were calculated using Cohen's kappa. Blood samples for N­terminal pro brain natriuretic peptide (NT-pBNP) were obtained on the morning the Valsalva maneuver was performed. RESULTS: Blood pressure response was sinusoidal in 37 (42%), showed an absent overshoot in 17 (19%) and had a square wave pattern in 34 (38%) patients. Cohen's kappa was 0.911 (95% CI 0.837-0.985) for interrater reliability and 0.929 (95% CI 0. 0.862-0.996) for test-retest reliability. The interrater and test-retest agreement were 94% and 96%, respectively. The mean NT-pBNP plasma levels and the interquartile ranges (IQR) in subjects with types A, B and C blood pressure response pattern were 213 (153-324) pg/ml, 805 (622-1332) pg/ml and 3964 (2595-5906) pg/ml, respectively (p < 0.001). CONCLUSION: The blood pressure response during a Valsalva maneuver shows an excellent reliability in older subjects. The type of response is associated with the NT-pBNP plasma level.

Recommendations for the management of COVID-19 pandemic in long-term care facilities.

Long-term care facilities (LTCF) and their vulnerable residents are particularly affected by the coronavirus disease 2019 (COVID-19) pandemic. Estimates from various countries suggest that 3-66% of all COVID-19 deaths were residents of LTCF, of which 80% died in their facilities. Despite these significant numbers, recommendations for LTCF for the prevention and medical care of residents during the COVID-19 pandemic are still lacking. These recommendations are based on the existing literature and the expertise of the authors who are specialists in geriatric medicine. The recommendations are addressed to LTCF management, their operators, physicians working in LTCFs and also politicians, to provide the necessary framework conditions. We are confident that our recommendations will offer important help and guidance for LTCFs as well as their physicians. Adherence to these recommendations is likely to improve the outcomes and care of residents in long-term facilities during the COVID-19 pandemic.

[Limits and Ethics of Mechanical Ventilation and Intensive Care Medicine in Old Age]. / Grenzen und Ethik der Beatmung und Intensivmedizin im Alter.

Changing demography with more older people and more patients with chronic diseases as well as the progress of medicine leads to more geriatric patients treated in intensive care and requiring mechanical ventilation due to severe respiratory insufficiency.Frailty is associated with a more complicated intensive care stay, more difficult convalescence and with a higher mortality.In principle, geriatric expertise should be brought in as early as possible in the course of intensive care treatment for older patients in order to carry out adequate risk stratification and, depending on the extent of the impairment, to plan discharge or early rehabilitation.In older and frail patients preexisting chronic ventilatory insufficiency often leads to prolonged weaning. Patients with weaning failure should be referred to a specialized weaning center. Part of the assessment will be whether out-of-hospital invasive or non invasive ventilation is indicated and the wish of the patient.In intensive care the likelihood of a successful outcome and the patient's wishes must constantly be re-evaluated. This is particularly true in older patients. In addition it should be clarified with the patients and relatives what constitutes "success"; for example a patient may consider intensive care "worth it" if the ultimate goal is discharge to their own home but not if nursing home care and tracheostomy ventilation is the best that can be achieved. It may become apparent that a successful outcome is unlikely and then withdrawal of invasive ventilation is appropriate.

[COVID-19 in old age-The geriatric perspective]. / COVID-19 im Alter ­ Die geriatrische Perspektive.

Predominantly the older population is affected by a severe course of COVID-19. The mortality of hospitalized patients with COVID-19 above the age of 80 years is up to 54% in international studies. These observations indicate the necessity to highlight the geriatric perspective on this disease. The diagnostics and treatment of COVID-19 do not differ between younger and older patients but atypical symptoms should be expected more frequently in old age. Older subjects show an increased need for rehabilitation after COVID-19. Paradoxically, increasing rehabilitation demands go along with a reduced availability of geriatric rehabilitation options, the latter being a consequence of closure or downsizing of rehabilitation departments during the pandemic. In general, measures of isolation and quarantine should be diligently balanced as the health and emotional consequences of such measures may be severe in older persons. In light of the poor prognosis of older COVID-19 patients, advanced care planning becomes even more relevant. Caregivers and physicians should be encouraged to compose advanced care directives that also reflect the specific circumstances of COVID-19. Fortunately, current data suggest that the effectiveness of the vaccination with the mRNA-vaccines approved in Germany may be equally high in older compared to younger persons.

[Management of Adult Community-Acquired Pneumonia and Prevention - Update 2021 - Guideline of the German Respiratory Society (DGP), the Paul-Ehrlich-Society for Chemotherapy (PEG), the German Society for Infectious Diseases (DGI), the German Society of Medical Intensive Care and Emergency Medicine (DGIIN), the German Viological Society (DGV), the Competence Network CAPNETZ, the German College of General Practitioneers and Family Physicians (DEGAM), the German Society for Geriatric Medicine (DGG), the German Palliative Society (DGP), the Austrian Society of Pneumology Society (ÖGP), the Austrian Society for Infectious and Tropical Diseases (ÖGIT), the Swiss Respiratory Society (SGP) and the Swiss Society for Infectious Diseases Society (SSI)]. / Behandlung von erwachsenen Patienten mit ambulant erworbener Pneumonie ­ Update 2021.

The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.

[Less can be more-Examples on medication in older and geriatric patients from current studies]. / Weniger kann mehr sein ­ Beispiele zur Medikation bei älteren und geriatrischen Patienten aus aktuellen Studien.

Polypharmacy, i.e. the prescription of five or more different drugs for medicinal treatment, is a typical problem in older and geriatric patients. Polypharmacy predisposes to different negative health sequelae, such as undesired side effects, drug interactions, potentially inappropriate medication, reduced functional abilities, increased hospitalization and increased mortality. Various consensus groups and specialist societies have developed recommendations on how to handle polypharmacy in geriatric patients. Although concepts to reduce the number of drugs are considered necessary, in many areas there is a lack of evidence on how to limit polypharmacy in geriatric patients and to reduce and discontinue medication. This article presents examples of recent studies dealing with potentially inappropriate medication, vitamin D substitution and antipsychotic drugs, which show how to critically appraise a prescribed medication, to critically check the indications for drugs and to discontinue drug use.

Abnormal things happening during sleep: parasomnias.

Parasomnias are characterized by abnormal experiences, dreams, movements and behavior during sleep. They may occur in the middle of the sleep during REM (rapid eye movement) or NREM (non-rapid eye movement), during falling asleep or waking up. Characteristically for REM behavior disorder is an increased muscle tone although usually REM is defined by an absence of muscle tone. For these forms aggressive dreams may lead to violating bed partners or self-injury of the sleeping person. Even killing bed partners has been described. Many of the patients develop a kind of Parkinson's disease (synucleinopathies). The rate of phenoconversion is more than 30% in 5 years and nearly 100% after 15 years. There are several recommendations regarding a safe sleeping environment. Medicinal treatment consists of either melatonin or clonazepam.

[Geriatrics in times of corona]. / Geriatrie in Zeiten von Corona.

The current corona crisis affects older patients as well as the geriatric infrastructure in all sectors. This article provides an overview about the current state of knowledge on COVID-19 with special consideration of geriatric aspects and the consequences for the geriatric care system.

Does the identification of seniors at risk (ISAR) score effectively select geriatric patients on emergency admission?

The number of older patients admitted to emergency departments (ED) increases continuously. The Identification of Seniors at Risk (ISAR) score is currently recommended to screen patients in German ED, but its appropriateness is being criticized. ISAR scores and clinical characteristics from 98 emergency admissions (EA), 80 from acute geriatrics (AG) and 89 from a geriatric rehabilitation (GR) unit were compared retrospectively. No significant differences were found between groups, being the ISAR score positive in 87.7% of EA, 94.9% of AG and 94.4% of GR cases. None of positively identified geriatric patients in the EA was transferred to the geriatric ward of competence. EA patients showed significantly higher number of functional impairments (p = 0.001) and higher BI score (p < 0.0001) compared to AG and GR groups. A higher ISAR score threshold and additional functional information might be needed to better select patients in need of prompt treatment by a geriatric team.

[Geriatric Trauma Center DGU®: Evaluation of clinical and economic parameters : A pilot study in a german university hospital]. / AltersTraumaZentrum DGU®: Evaluation klinischer und ökonomischer Parameter : Eine Pilotstudie an einer deutschen Universitätsklinik.

BACKGROUND: Previous studies on orthogeriatric models of care suggest that there is substantial variability in how geriatric care is integrated in the patient management and the necessary intensity of geriatric involvement is questionable. OBJECTIVE: The aim of the current prospective cohort study was the clinical and economic evaluation of fragility fracture treatment pathways before and after the implementation of a geriatric trauma center in conformity with the guidelines of the German Trauma Society (DGU). METHODS: A comparison of three different treatment models (6 months each) was performed: A: Standard treatment in Orthopaedic Trauma; B: Special care pathways with improvement of the quality management system and implementation of standard operating procedures; C: Interdisciplinary treatment with care pathways and collaboration with geriatricians (ward round model). RESULTS: In the 151 examined patients (m/w 47/104; 83.5 (70-100) years; A: n = 64, B: n = 44, C: n = 43) pathways with orthogeriatric comanagement (C) improved frequency of postoperative mobilization (p = 0.021), frequency of osteoporosis prophylaxis (p = 0.001) and the discharge procedure (p = 0.024). In comparison to standard treatment (A), orthogeriatric comanagement (C) was associated with lower rates of mortality (9% vs. 2%; p = 0.147) and cardio-respiratory complications (39% vs. 28%; p = 0.235) by trend. In this context, there were low rates of myocardial infarction (6% vs. 0%), dehydration (6% vs. 0%), cardiac dysrhythmia (8% vs. 0%), pulmonary decompensation (28% vs. 16%), electrolyt dysbalance (34% vs. 19%) and pulmonary edema (11% vs. 2%). Duration of stay in an intensive care unit was 29 h (A) and 18 h (C) respectively (p = 0.205), with consecutive reduction in costs. A sole establishment of a special care pathway for older hip fracture patients (B) showed a lower rate of myocardial infarction (A: 11%, B: 0%, C: 0%; p = 0.035). CONCLUSION: There was a clear tendency to a better overall result in patients receiving multidisciplinary orthogeriatric treatment using a ward visit model of orthogeriatric comanagement, with lower rates of cardiorespiratory complications and mortality. While special care pathways could reduce the rate of myocardial infarction in hip fracture patients, costs and revenues showed no difference between all care models evaluated. However, patients with hip fracture or periprosthetic fracture represent cohorts at clinical and economic risk as well.

[Soft skills : Somewhat different doping]. / Soft Skills : Etwas anderes Doping.

Doping actually means the taking of illegal substances or the use of forbidden methods to increase or maintain performance. Diseases associated with age and functional decline can lead to constraints in the activities of daily living and this leads to loss of autonomy; therefore, doping in its different variations is used to try to achieve performance, which would not otherwise be possible. A somewhat different method is soft skills, i.e. personal, social and methodological competences, which are adopted to remain fit with the help of selection and compensation. One of the main cornerstones for healthy aging apart from medical interventions is physical activity and to keep training up to old age. An early beginning with sports activities and to continue practicing sport in a variety of forms into old age, plays a decisive role in healthy aging. There are also many recommendations for nutrition, such as changing eating habits and the composition of nourishment to counteract the process of aging. With increasing age the interests and life style also change and therefore early planning is absolutely necessary. Preservation of cognitive capabilities is one of the most important requirements to overcome aging. Not only the cognitive resources must be promoted but also attention must be paid to the resilience to deal with losses. Resilience plays a key role. People with a positive attitude to living with old age show less functional physical impairment and recover from illness more quickly. Humor, optimism and physical activity are crucial for successful aging.

[Influenza: special aspects in old age]. / Influenza: besondere Aspekte im höheren Lebensalter.

In Germany up to 20% of the population are affected by influenza every year. Particularly for the elderly, influenza is related to high morbidity and mortality and 90% of deaths are related to the group of 60 years and older. In this context, seasonal influenza caused by influenza A (H3N2) viruses is exceedingly relevant for the elderly. The aging of the immune system, immunosenescence, is well documented as the cause of increased susceptibility to infection and change of typical symptoms. This can cause a delay in diagnosing and treatment of influenza infections. Furthermore, immunosenescence can lead to decreased efficacy of vaccination. Adjuvanted vaccines and vaccines with higher antigen content cause an enhanced immune response and are therefore especially suitable for prevention. The Standing Vaccination Committee (STIKO) recommends vaccination against seasonal influenza for all persons 60 years of age and over as well as for nursing home residents, pregnant women and chronically ill patients. For the coming influenza season 2018/19, the STIKO generally recommends the administration of quadrivalent (tetravalent) vaccines for the first time.

[Management of osteoporosis after fragility fractures]. / Management der Osteoporose nach Fragilitätsfrakturen.

Osteoporosis is defined as a systemic bone disease with decreased bone strength and an increased susceptibility for fractures. Older people in particular face an increased risk of fractures. These kind of fractures are usually caused by an inadequate trauma and are the so-called fragility fractures. In older adults immediate fracture stabilization and early mobilization have become the standard procedure after a fragility fracture. Treatment of the underlying osteoporosis often plays a minor role in clinical practice. Only a small group of patients are already under osteoporosis medication and even after a fracture occurs only few patients receive osteoporosis drug treatment with the aim to reduce the progression of osteoporosis and to reduce subsequent fractures. In the literature this has been described as the osteoporosis care gap. The following article presents an overview of treatment options and answers many different questions from the clinical routine.

[Vaccination in advanced age]. / Impfungen im höheren Lebensalter.

Infectious diseases are responsible for up to 5% of fatalities even in developed countries. In addition, there is an increasing susceptibility for infections in elderly people due to physiological aging of the immune system. The principles of vaccination are based on a targeted activation of the human immune system. Principally, a distinction is made between passive immunization, i.e. the application of specific antibodies against a pathogen and active immunization. In active immunization, i.e. vaccination, weakened (attenuated) or dead pathogens or components of pathogens (antigens) are administered. After a latency period that depends on the vaccine, complete immune protection is achieved and immunity is maintained for a certain period of time. In contrast to dead vaccines, by the use of live vaccines there is always a risk for infection with the administered vaccine. In passive immunization antibodies are administered. As a rule passive immunization is carried out in persons who have had contact with an infected person and in whom no or uncertain immunity against the corresponding disease is present. Based on the recommendations of the Standing Committee on Vaccination (STIKO), influenza, pneumococcal, herpes zoster, early summer meningoencephalitis (FSME) and travel vaccines are described.

[Position Paper on Adult Pneumococcal Vaccination: Position Paper of the German Respiratory Society and the German Geriatric Society]. / Stellungnahme zur Empfehlung der Pneumokokken-Impfung für Erwachsene: Positionspapier der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin (DGP) und der Deutschen Gesellschaft für Geriatrie (DGG).

Currently, the German Advisory Committee on Immunization Practices recommends the pneumococcal polysaccharide vaccine (PSV23) instead oft the pneumococcal conjugate vaccine (PCV13) for standard vaccination of adults > 60 years. Whereas the efficacy of PSV23 against bacteraemia has been proven by numerous studies, there is increasing evidence that there is no efficacy against non-bacteraemic pneumococcal pneumonia. This is in contrast to PCV13, for which the CAPITA study has recently revealed an efficacy of 45% against non-bacteraemic pneumonia by the 13 vaccine types.In this position paper we argue that this decision is not justified by the available evidence for the following reasons: i) the main burden of pneumococcal diseases is non-bacteraemic pneumoniaii) the clinical evidence for the efficacy against pneumonia is of higher quality for PCV13 than for PSV23 iii) the duration of clinical efficacy PSV23 starts to decrease after 2 years, whereas this has not yet been observed for PCV13 in the CAPITA study for at least four years, and iv) herd protection effects observed after PCV7 infant vaccination program on invasive pneumococcal disease must not be extrapolated to PCV13 and non-invasive pneumococcal diseases.

[Risk scores for community acquired pneumonia in elderly and geriatric patients]. / Risiko-Scores zur ambulant erworbenen Pneumonie bei älteren und geriatrischen Patienten.

BACKGROUND: Community-acquired pneumonia (CAP) is still an important and serious disease for elderly and geriatric patients. AIMS: For epidemiological and clinical reasons it is important to collate the frequencies of the various degrees of severity of CAP and to obtain information on the spread and degree of the threat to the various risk groups by CAP. In outpatient treatment a simple to execute prognosis score can be used to objectify the assessment of the clinical status of a patient and to support therapeutic decision-making. For this purpose knowledge of the appropriate instruments should be available to potential users. MATERIAL AND METHODS: Since the 1990s a variety of risk scores for stratification of CAP have been developed and evaluated. This article presents the content and value of the available risk scores whereby the advantages and disadvantages of the individual scores are critically compared. Special emphasis is placed on the importance of the risk scores for geriatric patients. RESULTS: At present the decision about outpatient or inpatient treatment is primarily based on the risk score CRB-65. Criteria for intensive care unit admissions are provided by the modified American Thoracic Society (ATS) set of criteria. Overall, risk scores are less reliable for elderly patients than for younger adults. CONCLUSION: For treatment decisions for the elderly, functional aspects should also be considered in addition to the aspects of risk scores discussed here. In particular, the decision about inpatient admission for elderly, geriatric CAP patients should be made on an individual basis taking the benefit-risk relationship into consideration.