[Atrial fibrillation and impairment of cognition-importance for geriatrics]. / Vorhofflimmern und kognitive Störung ­ Bedeutung für die Geriatrie.

According to the current study situation an independent association between atrial fibrillation and cognitive impairment is likely. Several pathomechanisms seem to be causative: embolisms in particular appear to cause clinically inapparent cerebral infarction and thus a deterioration of cognitive status but hypoperfusion and possibly subsequent atrophy of the gray matter can also play a role. There are indications but not yet sufficient evidence for protective effects of anticoagulation, rhythm control and possibly frequency regulation.

Presbyphagia Diagnostics Using M-Mode Ultrasound: Changes in the Tongue Movement Pattern.

Age-related physiological changes of the swallowing act impair particularly the oral phase and the tongue function, which is very important for bolus preparation and transfer. At present, there are no easily applicable methods for measurement of this phase of swallowing. This study was designed to investigate the deglutitive tongue movement by M-mode ultrasound and to compare the collected parameters of different age groups. In this exploratory prospective study, the tongue and its movements of 20 younger and 30 older women were examined during swallowing by B-mode and M-mode ultrasound. Preexisting dysphagia or malnutrition as well as psychic or neurological deficits were excluded by clinical examination and screening with the Mini Nutritional Assessment-Short Form (MNA-SF), the Gugging Swallowing Screen (GUSS), the Mini-Mental State Examination (MMSE) and the Barthel Index. The data were compared with each other and statistically analyzed. With increasing age, a change in the tongue movement pattern becomes apparent. In the group of older women, the vertical lingual movement had a smaller amplitude (p < 0.001) and a shorter time to the maximum amplitude (p < 0.03) than in the group of younger women. However, there were no differences in the tongue diameter (p > 0.4). The tongue movement pattern appears to be subject to age-specific changes, in contrast to anatomy. The use of M-mode ultrasonography is an easy, radiation-free and cost-effective method for the assessment of the oral phase of swallowing. Limitations are the widely scattered values of the ultrasound findings. Further studies are needed for validation and definition of standard values for this promising method.

[Special care units for patients with cognitive impairment : Results of a nationwide survey in geriatric hospitals in Germany]. / Spezialstationen für Patienten mit kognitiver Einschränkung : Ergebnisse einer Umfrage in Kliniken für Geriatrie in Deutschland.

BACKGROUND: A large number of older acutely ill patients with cognitive impairment are treated in geriatric care units. Since 1990 some geriatric departments in Germany have established special care units (SCU) for this patient population. In 2010 the first inventory of SCUs in Germany was carried out, which was not based on a nationwide systematic survey. OBJECTIVE: Nationwide systematic survey of SCUs for patients with cognitive impairment in geriatric institutions in Germany. METHODS: An online questionnaire (SurveyMonkey®, San Mateo, CA, USA) was sent to all heads of geriatric departments that provide advanced education in geriatric medicine of at least 12 months as registered by the German Society for Geriatric Medicine (DGG). RESULTS: The questionnaire was sent to 495 geriatric institutions of which 161 answered (response rate 32.5%). Additionally, 13 institutions answered through a weblink sent in a newsletter by the DGG. In 2017 a total of 42 SCUs existed with a mean size of 13.5 ± 4.7 beds. A further 15 hospitals plan to install an SCU in the near future, 5 probably in 2018. In four geriatric departments an existing SCU was closed down. All SCUs implemented special architectural, structural and personnel measures as recommended by the position paper of the DGG. The few conducted evaluations indicated beneficial results for mobility and disruptive behavior. CONCLUSION: In recent years the number of SCUs has increased considerably. A methodologically sound evaluation with respect to patient-related outcomes including follow-up and cost-effectiveness is lacking and should be carried out in the near future.

Asymptomatic and yet C. difficile-toxin positive? Prevalence and risk factors of carriers of toxigenic Clostridium difficile among geriatric in-patients.

BACKGROUND: Clostridium difficile infections (CDI) are the most frequent cause of diarrhoea in hospitals. Geriatric patients are more often affected by the condition, by a relapse and complications. Therefore, a crucial question is how often colonization with toxigenic Clostridium difficile strains occurs in elderly patients without diarrhoea and whether there is a "risk pattern" of colonized patients that can be defined by geriatric assessment. Furthermore, the probability for those asymptomatic carriers to develop a symptomatic infection over time has not been sufficiently explored. METHODS: We performed a cohort study design to assess the association of clinical variables with Clostridium difficile colonization. The first stool sample of 262 consecutive asymptomatic patients admitted to a geriatric unit was tested for toxigenic Clostridium difficile using PCR (GeneXpert, Cepheid). A comprehensive geriatric assessment (CGA) including Barthel Index, Mini Mental State Examination (MMSE) and hand grip-strength was performed. In addition, Charlson Comorbidity Index, body mass index, number and length of previous hospital stays, previous treatment with antibiotics, institutionalization, primary diagnoses and medication were recorded and evaluated as possible risk factors of colonization by means of binary logistic regression. Secondly, we explored the association of C. difficile colonization with subsequent development of CDI during hospital stay. RESULTS: At admission, 43 (16.4%) patients tested positive for toxin B by PCR. Seven (16.3%) of these colonized patients developed clinical CDI during hospital stay, compared to one out of 219 patients with negative or invalid PCR testing (Odds ratio 12,3; Fisher's exact test: p = 0.000). Overall, 7 out of 8 (87.5%) CDI patients had been colonized at admission. Risk factors of colonization with C. difficile were a history of CDI, previous antibiotic treatment and hospital stays. The parameters of the CGA were not significantly associated with colonization. CONCLUSION: Colonization with toxigenic Clostridium difficile strains occurs frequently in asymptomatic patients admitted to a geriatric unit. Previous CDI, antibiotic exposure and hospital stay, but not clinical variables such as CGA, are the main factors associated with asymptomatic Clostridium difficile carriage. Colonization is a crucial risk factor for subsequent development of symptomatic CDI.

Comparability and imprecision of 8 frequently used commercially available immunoassays for therapeutic drug monitoring.

BACKGROUND: The development of new immunoassays for therapeutic drug monitoring and the adaptation of current assays on new analytical platforms has led to a plethora of different tests. This variability may influence comparability between the methods and affect interpretation of test results used for guiding drug treatment. METHODS: Comparability and imprecision of 8 immunoassays for therapeutic drug monitoring were evaluated using 6 different analyzers from 3 manufacturers. Current and previous generation analytical systems used were Architect and AxSym (Abbott Laboratories), cobas c 501 module and COBAS INTEGRA 800 analyzer (Roche Diagnostics GmbH), and Dimension Vista and Dimension Xpand (Siemens Healthcare Diagnostics Inc). Carbamazepine, digoxin, phenobarbital, phenytoin, theophylline, tobramycin, vancomycin, and valproic acid were measured using leftover routine samples. RESULTS: Good performance and comparability of the drug assays was seen on all systems for carbamazepine, phenytoin, and valproic acid except for phenytoin on the Dimension Vista. Deviations from the acceptance criteria were found with digoxin, phenobarbital, theophylline, tobramycin, and vancomycin. Despite a change of the analytical principle on the Roche systems for most drugs, the results demonstrated a very good between-system comparability of the concentration measured. Systematic deviations were found between AxSYM and ARCHITECT for digoxin, phenobarbital, and tobramycin, and between Dimension Xpand and Dimension Vista for digoxin and vancomycin. CONCLUSIONS: The study revealed differences between assays, platforms, and assay principles. Care should be taken if methods or instruments are replaced in a laboratory. Laboratories are advised to perform their own method comparison studies and to inform their customers about the effect on the therapeutic ranges in case of observed clinically significant deviations.

Hydration Status Assessment in Older Patients.

BACKGROUND: Hydration disturbances are common in old age: the reported prevalence of dehydration in elderly patients ranges from 19% to 89%, depending on the definition and the population in question. However, the clinical assessment of patients' hydration status is difficult. In this review, we discuss the diagnostic value of currently used methods that may or may not be suitable for assessing older patients' hydration status. METHODS: We conducted a selective literature search for relevant studies concerning patients aged 65 and above. Of the 355 articles retrieved by the initial search, a multistep selection process yielded 30 that were suitable for inclusion in this review. RESULTS: 107 different methods for the diagnostic assessment of dehydration in older persons were evaluated on the basis of the reviewed publications. High diagnostic value, especially for the determination of hyperosmolar dehydration, was found for serum osmolality, serum sodium concentration, inferior vena cava ultrasonography, a history (from the patient or another informant) of not drinking between meals, and axillary dryness. On the other hand, a variety of clinical signs such as a positive skin turgor test, sunken eyes, dry mouth, tachycardia, orthostatic dysregulation, and dark urine were found to be of inadequate diagnostic value. CONCLUSION: Only five of the 107 methods considered appear to be suitable for determining that a patient is dehydrated. Thus, the available scientific evidence indicates that all clinicians should critically reconsider their own techniques for assessing hydration status in elderly patients. To optimize the clinical assessment of patients' hydration status, there seems to be a need for the rejection of unsuitable methods in favor of either newly developed criteria or of a combination of the best criteria already in use.

Effects of subcortical vascular ischemic dementia and aging on negative and neutral word list learning.

BACKGROUND: Subcortical ischemic vascular dementia (SIVD) represents an important subgroup of vascular dementia. Besides characteristic cognitive deficits, particular emotional problems support the diagnosis. Emotional disturbances in SIVD are not well understood. METHOD: We studied the performance of SIVD patients, healthy young control persons and old control persons in an emotional word list learning task. RESULTS: SIVD patients showed lower memory performance than both control groups for neutral as well as for negative words. However, we found a significant emotional memory advantage for negative words in all 3 diagnostic groups. CONCLUSION: SIVD patients are able to profit from emotional information in order to enhance their memory performance.

Low Self-Perception of Malnutrition in Older Hospitalized Patients.

BACKGROUND: Studies focusing on self-perception of nutritional status in older hospitalized patients are lacking. We aimed to examine the self-perception of body weight and nutritional status among older hospitalized patients compared to their actual body weight and nutritional status based on medical assessment. MATERIALS AND METHODS: This observational cross-sectional study investigated 197 older participants (mean age 82.2±6.8 years, 61% women) who were consecutively admitted to the geriatric acute care ward. Body weight status and nutritional status were assessed using WHO-BMI classification and Mini Nutritional Assessment-Short Form (MNA-SF), respectively. Self-perceived body weight status and nutritional status were assessed with a standardized questionnaire. A follow-up was performed with a short telephone interview after three months. RESULTS: According to MNA-SF, 49% and 35% were at risk of malnutrition and malnourished, respectively. There was no agreement between self-perceived nutritional status and objective nutritional status according to MNA-SF (Kappa: 0.06). A slight agreement was found between subjective body weight status and objective body weight status according to WHO-BMI classification (Kappa: 0.19). A total of 184 patients completed the 3 months follow-up and additional 9 patients died during this time, of which 7 and 2 were malnourished and at risk of malnutrition according to MNA-SF, respectively. Of those who were malnourished and at risk of malnutrition based on MNA-SF and died during follow-up, 67.7% did not realize their malnutrition. Compared to the patients with normal nutritional status during hospitalization, malnourished patients based on MNA-SF had higher rates of unplanned hospital readmission and further weight loss and more often reported health deterioration and experienced death within three months after discharge. CONCLUSION: No agreement between self-perceived nutritional status and objective nutritional status among older hospitalized patients was found. Our study highlights the need to raise knowledge about the issue of malnutrition and increase awareness of health risks associated with malnutrition among older hospitalized patients.

Adherence to medication in patients with dementia: predictors and strategies for improvement.

Measures to facilitate patient medication adherence should be considered an integral part of the comprehensive care of older patients with multiple diseases. However, impairment of cognitive functions and dementia, in particular, may substantially compromise adherence behaviour. Therefore, a literature review was performed to identify factors associated with adherence to medication in patients with cognitive impairment or dementia, and to discuss strategies for improvement of non-adherence. Evidence-based information on how to deal with adherence to medication in patients with dementia is scarce because of a lack of specific studies. However, there is increasing knowledge about factors influencing medication adherence behaviour in older age, and emerging insight into the relationships between adherence behaviour and cognitive capacity, memory and executive function, in particular. Nevertheless, understanding elderly persons' strategies for maintaining regular use of even complex drug regimens is still limited. Progress of research in this field is needed. It is notable that measures to improve adherence consist of combinations of educational interventions and cognitive support but assessment of study participants' cognitive function is rare. In clinical practice, awareness of non-adherence as a result of cognitive impairment is relatively low. The most important step is early detection of cognitive impairment when this is impacting negatively on medication management. A practical geriatric screening test is recommended to identify memory problems and further functional impairments associated with cognitive impairment. Performance-based assessments might be useful for screening medication management capacity, in addition to a careful drug history, inspection of all medicines used (including over-the-counter drugs) and proxy information. However, no feasible screening methods have as yet found their way into clinical practice. Patients with impaired executive function, lack of awareness of illness and personality traits such as independency and high self-confidence may be at particular risk of non-adherence. The question is when to switch patient medication self-management to another person's responsibility if cognitive decline progresses. Further research is needed on measures to differentiate cognitive function and the relationships between memory concerns, memory strategy use and medication management. Also, studies evaluating the influence of personal support, health status and depression on the memory strategies used are needed. It is important to assess patients' attitudes toward medication and their relationship with proxies. Strategies for facilitating medication adherence in patients with dementia include prescribing as few medicines as possible, tailoring dose regimens to personal habits, and coordinating all drug dosing schedules as much as possible. When providing medication organizers, it is important to observe the patient's ability to use devices appropriately. In addition, automated computer-based reminding aids, online medication monitoring and telemonitoring may be helpful for patients with mild dementia. The decision as to when assistance with medication self-management is needed has to be made taking into account patient independency and safety aspects. This holds true for medicines with a narrow therapeutic range, in particular. Interactions among the individual patient's cognitive status, mood, level of self-efficacy and particular living situation must also be taken into consideration when searching for the optimal medication adherence strategy. No evidence-based recommendations can be given as yet. However, comprehensive assessment of the individual patient and careful consideration of all potential drug-related problems will probably help facilitate adherence and prevent compromised health outcomes in patients with dementia.

The sensory cortical representation of the human penis: revisiting somatotopy in the male homunculus.

Pioneering mapping studies of the human cortex have established the notion of somatotopy in sensory representation, which transpired into Penfield and Rasmussen's famous sensory homunculus diagram. However, regarding the primary cortical representation of the genitals, classical and modern findings appear to be at odds with the principle of somatotopy, often assigning it to the cortex on the mesial wall. Using functional neuroimaging, we established a mediolateral sequence of somatosensory foot, penis, and lower abdominal wall representation on the contralateral postcentral gyrus in primary sensory cortex and a bilateral secondary somatosensory representation in the parietal operculum.

Oropharyngeal dysphagia in older persons - from pathophysiology to adequate intervention: a review and summary of an international expert meeting.

Oropharyngeal dysphagia (OD) is a highly prevalent and growing condition in the older population. Although OD may cause very severe complications, it is often not detected, explored, and treated. Older patients are frequently unaware of their swallowing dysfunction which is one of the reasons why the consequences of OD, ie, aspiration, dehydration, and malnutrition, are regularly not attributed to dysphagia. Older patients are particularly vulnerable to dysphagia because multiple age-related changes increase the risk of dysphagia. Physicians in charge of older patients should be aware that malnutrition, dehydration, and pneumonia are frequently caused by (unrecognized) dysphagia. The diagnosis is particularly difficult in the case of silent aspiration. In addition to numerous screening tools, videofluoroscopy was the traditional gold standard of diagnosing OD. Recently, the fiberoptic endoscopic evaluation of swallowing is increasingly utilized because it has several advantages. Besides making a diagnosis, fiberoptic endoscopic evaluation of swallowing is applied to evaluate the effectiveness of therapeutic maneuvers and texture modification of food and liquids. In addition to swallowing training and nutritional interventions, newer rehabilitation approaches of stimulation techniques are showing promise and may significantly impact future treatment strategies.

The "zoom lens" of focal attention in visual search: changes in aging and Alzheimer's disease.

Visual search for a target in an array of distractors relies upon flexible shifts between global and local modes of attentional processing. Visual search is slowed in patients with Alzheimer's disease (AD), in part due to an increase in the number and duration of eye fixations made en route to a target (Rösler et al., 2000). This phenomenon may represent a compensatory adaptation to a narrowing of the zone of focal attention, necessitating more shifts of gaze in order to attend to the global workspace. Eye fixations were analyzed in two regions of interest (ROIs, central fixation and peripheral target locations) in 9 patients with mild AD, 9 cognitively intact age-matched control subjects, and 9 young controls, while they searched for a target object in a radial array that contained from 1 to 6 stimuli. Contrasted with young subjects, the search strategy of older controls and, to a greater extent, AD patients showed an increase in the average number and duration of peripheral fixations. Reduced efficiency of visual search in AD may be contributed to by reduced ability to dynamically adjust the attentional zoom, coupled with the inability to disengage attention from peripheral targets.

The attentional field has a Mexican hat distribution.

We assessed the interference by distracter letters on target discrimination as a function of the distance between incompatible distracters and target. The slope of the response time-distance function supports a Mexican hat pattern of attentional modulation in the visual field. We relate the results to our recent finding of neural activity suppression in primary visual cortex coding locations in the vicinity of an attended region [Muller, N. G., & Kleinschmidt, A. (2004). The attentional 'spotlight's' penumbra: Center-surround modulation in striate cortex. Neuroreport, 15(6), 977-980]. As behavioral performance parallels activity modulation of primary visual cortex but not other areas we propose that perceptual capacities are determined by attentional response properties of V1.

Dysphagia in Dementia: Influence of Dementia Severity and Food Texture on the Prevalence of Aspiration and Latency to Swallow in Hospitalized Geriatric Patients.

OBJECTIVES: To evaluate influences of disease severity and food texture on prevalence and type of dysphagia in hospitalized geriatric patients. DESIGN: We screened for dysphagia in 161 geriatric inpatients with different forms of dementia and 30 control patients. MEASUREMENTS: Signs of aspiration were registered with 3 different food consistencies (water, apple puree, and slice of an apple) and the latency until the first swallow was documented. SETTING: Geriatric department of an academic teaching hospital in Hamburg, Germany. RESULTS: Compared with the controls, patients with dementia more often showed signs of aspiration. In the patients with dementia, signs of aspiration occurred more frequently with water (35.6%) than with a slice of an apple (15.1%) or apple puree (6.3%). We observed an inverse relationship between Mini-Mental State Examination score level and the suspected rate of aspiration, as well as with the length of latency until the first swallow of puree. CONCLUSIONS: The prevalence of dysphagia is high in patients with dementia, especially in patients with moderate to severe cognitive impairment. The relationships observed in this study encourage screening for dysphagia and adapting meal consistencies to prevent aspiration in patients with dementia.

Single-needle acupuncture alleviates gag reflex during transesophageal echocardiography: a blinded, randomized, controlled pilot trial.

OBJECTIVES: To study the effect of single-needle acupuncture in suppressing gag-reflex in transesophageal echocardiography (TEE). DESIGN: Prospective, blinded trial. Settings/locations: Patients with ischemic stroke or transient ischemic attack undergoing TEE because of presumed cardioembolic origin in a specialized stroke unit of the Johann Wolfgang Goethe-University, Frankfurt/Main, Germany. Subjects/Study interventions: Forty-one (41) patients were studied. Patients received single-needle acupuncture with a 0.2 x 13 mm disposable acupuncture needle (Suzhou Medical Appliances, China), 10-mm deep either at Chengjiang (midline between lower lip and chin) or superficially at a sham point (tip of the chin) during TEE or no acupuncture for alleviating gag reflex. OUTCOME MEASURES: Severity of gagging was rated on a visual-analogue scale. RESULTS: The acupuncture group experienced significantly less gagging than the sham group (p = 0.037) or the nonacupuncture group (p = 0.013). CONCLUSIONS: Acupuncture of CV24 is an easy to apply and effective method to reduce gag reflex during TEE.

Dementia as a cofactor for geriatric rehabilitation-outcome in patients with osteosynthesis of the proximal femur: a retrospective, matched-pair analysis of 250 patients.

A raising number of patients with osteosynthesis of the proximal femur and additional dementia will be seen in hospitals in the future due to demographic changes. There is an ongoing discussion, if and to what extent cognitive abilities do influence functional outcome in geriatric rehabilitation. We therefore compared 250 patients with osteosynthesis of the proximal femur of whom one half had additional dementia, by a matched-pair analysis for the improvement of mobility assessed by the mobility items of the Barthel Index and the Tinetti mobility index. Dementia was an important cofactor for the success of geriatric rehabilitation. Patients with additional dementia reached lower mobility scores at discharge. Also, patients with dementia had significantly more in-hospital falls. Furthermore, the study revealed that demented patients received less individual and group therapy per hospital day. The study underlines the need for specialized wards treating demented patients with additional illnesses.