Minimizing comprehensive geriatric assessment to identify deterioration of physical performance in a healthy community-dwelling older cohort: longitudinal data of the AEQUIPA Versa study.

BACKGROUND: It is important to identify the relevant parameters of physical performance to prevent early functional decline and to prolong independent living. The aim of this study is to describe the development of physical performance in a healthy community-dwelling older cohort aged 70+ years using comprehensive assessment over two years and to subsequently identify the most relevant predictive tests for physical decline to minimize assessment. METHODS: Physical performance was measured by comprehensive geriatric assessment. Predictors for the individual decline of physical performance by Principal Component and k-means Cluster Analysis were developed, and sensitivity and specificity determined accordingly. RESULTS: 251 subjects (Ø 75.4 years) participated in the study. Handgrip strength was low in 21.1%. The follow-up results of tests were divergent. Handgrip strength [- 16.95 (SD 11.55)] and the stair climb power test (power) [- 9.15 (SD 16.84)] yielded the highest percentage changes. Four most relevant tests (handgrip strength, stair climb power time, timed up & go and 4-m gait speed) were identified. A predictor based on baseline data was determined (sensitivity 82%, specificity 96%) to identify subjects characterized by a high degree of physical decline within two years. DISCUSSION: Although the cohort of older adults is heterogeneous, most of the individuals in the study exhibited high levels of physical performance; only a few subjects suffered a relevant decline within the 2-year follow-up. Four most relevant tests were identified to predict relevant decline of physical function. CONCLUSION: In spite of ceiling effects of the geriatric assessment in high-performers, we assume that it is possible to predict an individual's risk of physical decline within 2 years with four tests of a comprehensive geriatric assessment.

Socio-ecological vulnerability to tipping points: A review of empirical approaches and their use for marine management.

Sustainability in the provision of ecosystem services requires understanding of the vulnerability of social-ecological systems (SES) to tipping points (TPs). Assessing SES vulnerability to abrupt ecosystem state changes remains challenging, however, because frameworks do not operationally link ecological, socio-economic and cultural elements of the SES. We conducted a targeted literature review on empirical assessments of SES and TPs in the marine realm and their use in ecosystem-based management. Our results revealed a plurality of terminologies, definitions and concepts that hampers practical operationalisation of these concepts. Furthermore, we found a striking lack of socio-cultural aspects in SES vulnerability assessments, possibly because of a lack of involvement of stakeholders and interest groups. We propose guiding principles for assessing vulnerability to TPs that build on participative approaches and prioritise the connectivity between SES components by accounting for component linkages, cascading effects and feedback processes.

[Refeeding syndrome : Pathophysiology, risk factors, prevention, and treatment]. / Refeeding-Syndrom : Pathophysiologie, Risikofaktoren, Prophylaxe und Therapie.

Refeeding syndrome is a life-threatening complication that may occur after initiation of nutritional therapy in malnourished patients, as well as after periods of fasting and hunger. Refeeding syndrome can be effectively prevented and treated if its risk factors and pathophysiology are known. The initial measurement of thiamine level and serum electrolytes, including phosphate and magnesium, their supplementation if necessary, and a slow increase in nutritional intake along with close monitoring of serum electrolytes play an important role. Since refeeding syndrome is not well known and the symptoms can be extremely heterogeneous, this complication is poorly recognized, especially against the background of severe disease and multimorbidity. This overview aims to summarize the current knowledge and increase awareness about refeeding syndrome.

Co-location of passive gear fisheries in offshore wind farms in the German EEZ of the North Sea: A first socio-economic scoping.

Worldwide the renewable energy sector is expanding at sea to address increasing demands. Recently the race for space in heavily used areas such as the North Sea triggered the proposal of co-locating other activities such as aquaculture or fisheries with passive gears in offshore wind farms (OWFs). Our interdisciplinary approach combined a quantification of spatial overlap of activities by using Vessel Monitoring System and logbook data with a stakeholder consultation to conclude and verify on the actual feasibility of co-location. In the German Exclusive Economic Zone (EEZ) of the North Sea up to 90% of Danish and 40% of German annual gillnet fleet landings of plaice overlapped with areas where OWFs are developed. Our results indicated further that the international gillnet fishery could lose up to 50% in landings within the North Sea German EEZ when OWF areas are closed entirely for fisheries. No spatial overlap was found for UK potters targeting brown crab in the German EEZ. We further identified a number of key issues and obstacles that to date hinder an actual implementation of co-location as a measure in the marine spatial planning process: defining the legal base; implementation of safety regulations; delineation of minimum requirements for fishing vessels such as capacities, quotas, technical equipment; implementation of a licensing process; and scoping for financial subsidies to set up business. The stakeholder consultation verified the scientific findings and highlighted that all those points need to be addressed in a planning process. In the German EEZ we have shown that the socio-economic importance of spatial overlap varies within planning boundaries. Therefore we recommend an interdisciplinary bottom-up approach when scoping for suitable areas of co-location. Hence, an informed marine spatial planning process requires comprehensive and spatial explicit socio-economic viability studies factoring in also ecological effects of OWFs on target species.

[The De Morton Mobility Index for evaluation of early geriatric rehabilitation]. / Der De Morton Mobility Index zur Evaluation der geriatrischen Frührehabilitation.

BACKGROUND: The timed up and go (TUG) test and the Tinetti test are most frequently used in Germany to document the success of rehabilitation in early geriatric rehabilitation. However, there has been some uncertainty whether these instruments can describe the entire spectrum of mobility with adequate precision and whether they can be successfully applied for repeated assessments during rehabilitation. Against this background the De Morton Mobility Index (DEMMI) has been developed and validated. OBJECTIVE: The aim of this study was to evaluate the suitability of the DEMMI compared to the TUG and Tinetti tests in early geriatric rehabilitation. MATERIAL AND METHODS: Ceiling and floor effects of the DEMMI, the TUG test, the Tinetti test and the Barthel Index (BI) were determined. Correlations were calculated using the Spearman correlation coefficient. Effects on the DEMMI were estimated through multiple linear regression. RESULTS: A total of 144 patients with an average age of 84.91 years (SD ±5.77) and 65.97 % females participated in this study. The mean value for the DEMMI was 33.45 (SD ±15.37) points at admission and 43.90 (SD ±15.55) at discharge (n = 144). Floor effects were observed in the TUG test in 84.72 % (n = 122) of patients at admission and in 60.42 % (n = 87) at discharge. The DEMMI, Tinetti test and BI showed no floor or ceiling effects. The correlation between the DEMMI and the TUG test was -0.48 at admission and -0.49 at discharge, between the DEMMI and the Tinetti test 0.75 and 0.82, respectively and between the DEMMI and the BI 0.54 and 0.66, respectively (p < 0,01). CONCLUSION: Significant correlations with the TUG test, the Tinetti test and the BI, together with the lack of floor and ceiling effects provide evidence that the DEMMI is an appropriate tool to assess mobility in early geriatric rehabilitation. The lack of floor and ceiling effects appears to make the DEMMI a superior tool compared to the TUG test.

Energy and Protein Intake, Anthropometrics, and Disease Burden in Elderly Home-care Receivers--A Cross-sectional Study in Germany (ErnSIPP Study).

OBJECTIVE: To date, no study has examined the nutritional status and disease burden of elderly home-care receivers living in Germany. Aim of this cross-sectional study was, first, to assess disease burden and nutritional status, denoted in anthropometrics, and, second, to investigate associations between anthropometrics and disease burden. DESIGN: Cross-sectional multi-centre study. SETTING: Home-care receivers living in three urban areas of Germany in 2010. PARTICIPANTS: 353 elderly (>64 years) in home care (128 males aged 79.1 ±7.8 years, 225 females aged 82.0 ±7.5 years). MEASUREMENTS: Nutritional status was assessed by body mass index (BMI), mid upper arm circumference (MUAC) and calf circumference (CC). Medical conditions were assessed in personal interviews. A 3-day prospective nutrition diary was kept. Metric data are reported as mean±SD or median (interquartile range), p<0.05 was considered significant. RESULTS: Most participants were substantially (59%), and 11% severest in need of care. The seniors suffered from 5 (4-7) chronic diseases; dementia, depression, stroke, and respiratory illness were most prevalent (each 20-40%). More than one-third of participants had only moderate or poor appetite, nearly half were unable to eat independently. Chewing problems were reported for 52% of study participants, and more than one quarter of elderly had swallowing problems. Daily mean energy intake was 2017±528 kcal in men (n=123) and 1731±451 kcal in women (n=216; p<0.001). Mean protein intake amounted to 1.0 g/kg body weight. Mean BMI was 28.2±6.2 kg/m² (n=341), 14% of seniors had a BMI <22 kg/m² (including 4% with BMI <20 kg/m²). Critical MUAC (<22 cm) was indicated in 6% of subjects; and CC <31 cm in 11% of men, 21% of women (p<0.05). After adjusting for sex and age, BMI, MUAC and CC were negatively associated with high care level, hospitalization in the previous year, nausea/vomiting, prevalence of dementia, poor appetite, and eating difficulties like dependency, chewing and swallowing problems. CONCLUSION: We recommend to pay special attention to the nutritional status of elderly persons in home-care exhibiting named disease burden.

Inverse relationship between body mass index and mortality in older nursing home residents: a meta-analysis of 19,538 elderly subjects.

Body mass index (BMI) and mortality in old adults from the general population have been related in a U-shaped or J-shaped curve. However, limited information is available for elderly nursing home populations, particularly about specific cause of death. A systematic PubMed/EMBASE/CINAHL/SCOPUS search until 31 May 2014 without language restrictions was conducted. As no published study reported mortality in standard BMI groups (<18.5, 18.5-24.9, 25-29.9, ≥30 kg/m(2)), the most adjusted hazard ratios (HRs) according to a pre-defined list of covariates were obtained from authors and pooled by random-effect model across each BMI category. Out of 342 hits, 20 studies including 19,538 older nursing home residents with 5,223 deaths during a median of 2 years of follow-up were meta-analysed. Compared with normal weight, all-cause mortality HRs were 1.41 (95% CI = 1.26-1.58) for underweight, 0.85 (95% CI = 0.73-0.99) for overweight and 0.74 (95% CI = 0.57-0.96) for obesity. Underweight was a risk factor for higher mortality caused by infections (HR = 1.65 [95% CI = 1.13-2.40]). RR results corroborated primary HR results, with additionally lower infection-related mortality in overweight and obese than in normal-weight individuals. Like in the general population, underweight is a risk factor for mortality in old nursing home residents. However, uniquely, not only overweight but also obesity is protective, which has relevant nutritional goal implications in this population/setting.

Vitamin D status and physical function in nursing home residents: a 1-year observational study.

OBJECTIVE: Low vitamin D blood levels are highly prevalent in elderly people, particularly in nursing home residents (NHR). A relation between vitamin D levels and physical function (PF) is described in several studies in older adults; however, data on NHR are scarce and there is presently no information on the time course of vitamin D levels and PF in this population. The aim of the present study was to describe the 25-hydroxyvitamin D [25(OH)D] status of NHR at baseline (t1) and after 1 year (t2) to examine whether 25(OH)D blood levels are related to PF at t1 and at t2, and whether changes in 25(OH)D levels over 1 year are related to changes in PF. METHODS: All NHR (≥ 65 years) without tube-feeding and severe acute or end-stage disease were asked to participate. At t1 and t2 fasting blood samples were taken for the analysis of 25(OH)D serum levels and PF was estimated by activities of daily living (Barthel ADL) and measured by handgrip strength (HGS) and timed 'up and go' test (TUG). RESULTS: In total, 115 residents, aged 87 (82-93) years (all data in median and 1st-3rd quartile), showed the following values for PF: ADL 50 (20-65) points, HGS 40 (30-50) kPa and TUG 26 (18-31) s. Vitamin D deficiency (< 50 nmol/l) was present in 93.9 % (70.4 % < 25 nmol/l) at t1 and in 71.2 % (57.3 % < 25 nmol/l) at t2. At t1 and at t2 a weak correlation between vitamin D level and PF (Spearman's correlation coefficient t1: ADL r = 0.367, HGS r = 0.313; t2: ADL: r = 0.247; all p < 0.01) was observed. There was no correlation between changes in vitamin D levels over 1 year and changes in PF. CONCLUSIONS: Almost all NHR included in the study showed vitamin D deficiency. 25(OH)D levels were weakly correlated to PF at baseline and at follow-up, and an increase in vitamin D levels was not associated with positive effects on PF in this study.

Screening for malnutrition among nursing home residents - a comparative analysis of the mini nutritional assessment, the nutritional risk screening, and the malnutrition universal screening tool.

BACKGROUND: The European Society for Clinical Nutrition and Metabolism (ESPEN) has recommended the Mini Nutritional Assessment (MNA®), the Nutritional Risk Screening 2002 (NRS), and the Malnutrition Universal Screening Tool (MUST) for nutritional screening in various settings and age groups. While in recent years all three tools have been applied to nursing home residents, there is still no consensus on the most appropriate screening tool in this specific setting. AIM: The present study aims at comparing the MNA, the NRS, and the MUST with regard to applicability, categorization of nutritional status, and predictive value in the nursing home setting. METHOD: MNA, NRS, and MUST were performed on 200 residents from two municipal nursing homes in Nuremberg, Germany. Follow-up data on infection, hospitalization, and mortality were collected after six and again after twelve months. RESULTS: Among 200 residents (mean age 85.5 ± 7.8 years) the MNA could be completed in 188 (94.0%) and the NRS and MUST in 198 (99.0%) residents. The prevalence of 'malnutrition' according to the MNA was 15.4%. The prevalence of 'risk of malnutrition' (NRS) and 'high risk of malnutrition' (MUST), respectively, was 8.6% for both tools. The individual categorization of nutritional status showed poor agreement between NRS and MUST on the one hand and MNA on the other. For all tools a significant association between nutritional status and mortality was demonstrated during follow-up as classification in 'malnourished', respectively 'high risk of malnutrition' or 'nutritional risk', was significantly associated with increased hazard ratios. However, the MNA showed the best predictive value for survival among well-nourished residents. CONCLUSION: The evaluation of nutritional status in nursing home residents by MNA, NRS, and MUST shows significant differences. This observation may be of clinical relevance as nutritional intervention is usually based on screening results. As the items of the MNA reflect particularities of the nursing home population, this tool currently appears to be the most suitable one in this setting.

Malnutrition is related to functional impairment in older adults receiving home care.

OBJECTIVES: The aims of this work were (a) to provide a detailed description of the association between nutritional (Mini Nutritional Assessment; MNA®) and functional status in a sample of older adults receiving home care, using both questionnaire- and performance-based functional methods, and (b) to investigate the impact of different MNA subscales on this association. DESIGN: Multi-centre, cross-sectional. SETTING: Home care. PARTICIPANTS: 296 persons ≥65 years in need of care (80.7±7.7 y). MEASUREMENTS: Nutritional status was determined by the MNA and functional status by two questionnaires (Instrumental and Basic Activities of Daily Living; IADL, ADL) and three performance tests (handgrip strength, HGS; Short Physical Performance Battery, SPPB; Timed 'Up and Go' Test, TUG). A categorical and a covariance analytical approach were used to test for differences in functional status between MNA groups (well nourished, risk of malnutrition, malnourished). In addition, functional parameters were correlated with total MNA, a modified MNA version (modMNA), where functional items were excluded, and MNA subscales ('functionality', 'general assessment', 'anthropometry', 'dietary assessment', and 'subjective assessment'). RESULTS: 57% of the participants were at risk of malnutrition and 12% malnourished. 35% reported severe limitations in IADL, 18% in ADL. 40%, 39% and 35% had severe limitations in HGS, SPPB and TUG; 9%, 28% and 34% were not able to perform the tests. Functional status deteriorated significantly from the well nourished to the malnourished group in all functional measures. The modMNA was weak but still significantly related to all functional parameters except TUG. The subscale 'functionality' revealed strongest correlations with functional measures. All other MNA subscales showed only weak or no associations. CONCLUSION: More than one half of the seniors receiving home care were at nutritional risk and poor functional level, respectively. Malnutrition according to MNA was significantly associated to both questionnaire- and performance-based functional measures even after exclusion of functional MNA items.

Nutritional status according to the mini nutritional assessment (MNA®) and frailty in community dwelling older persons: a close relationship.

OBJECTIVE: This study investigates the association between MNA results and frailty status in community-dwelling older adults. In addition the relevance of singular MNA items and subscores in this regard was tested. DESIGN: Cross-sectional study. SETTING: Community-dwelling older adults were recruited in the region of Nürnberg, Germany. PARTICIPANTS: 206 volunteers aged 75 years or older without cognitive impairment (Mini Mental State Examination >24 points), 66.0% female. MEASUREMENTS: Frailty was defined according to Fried et al. as presence of three, pre-frailty as presence of one or two of the following criteria: weight loss, exhaustion, low physical activity, low handgrip strength and slow walking speed. Malnutrition (<17 points) and the risk of malnutrition (17-23.5 points) were determined by MNA®. RESULTS: 15.1% of the participants were at risk of malnutrition, no participant was malnourished. 15.5 % were frail, 39.8% pre-frail and 44.7% non-frail. 46.9% of the frail, 12.2% of the pre-frail and 2.2% of the non-frail participants were at risk of malnutrition (p<0.001). Hence, 90% of those at risk of malnutrition were either pre-frail or frail. For the anthropometric, dietary, subjective and functional, but not for the general MNA subscore, frail participants scored significantly lower than pre-frail (p<0.01), and non-frail participants (p<0.01). Twelve of the 18 MNA items were also significantly associated with frailty (p<0.05). CONCLUSIONS: These results underline the close association between frailty syndrome and nutritional status in older persons. A profound understanding of the interdependency of these two geriatric concepts will represent the basis for successful treatment strategies.

Low incidence of neoplasia in heart and heart-lung transplant recipients receiving triple-drug immunosuppression.

The risk of neoplasias developing after solid organ transplantation is markedly increased by immunosuppressive therapy. Lymphoma has been reported to develop in 13% of heart and in 33% of heart-lung transplant recipients treated with cyclosporine, and the incidence of skin carcinoma ranges between 6% and 16%. The incidence of posttransplant neoplasias with the use of lower loading and maintenance doses of cyclosporine as used in triple-drug immunosuppression is unknown. From December 1983 through August 1988, 134 heart and seven heart-lung transplants were performed at the University of Minnesota. All patients received a combination of cyclosporine, azathioprine, and prednisone. Survival was 94% at 1 and 90% at 3 years in heart recipients. Probability of acute rejection was 9% at 3 months and 12% at 1 and 3 years. B-cell lymphoma developed after heart transplant in only two patients for an incidence of 1.5%. Episodes of acute rejection and mean cyclosporine blood level did not predict the occurrence of posttransplant lymphoma. The incidence of skin carcinoma was 6.4%. No neoplasia occurred in heart-lung transplant recipients. All neoplasias were observed in patients older than 50 years. Our data indicate that the risk for developing lymphoproliferative disorders, but not for basal cell carcinoma, is reduced in heart and heart-lung transplant recipients receiving triple-drug immunosuppression. Older recipients may be at increased risk, suggesting that lower doses of immunosuppressive therapy should be considered in this group.

[Communication for patients with severe motor handicaps--clinical experience with a new electronic communication aid]. / Kommunikation für motorisch Schwerstbehinderte--Klinische Erfahrungen mit einer neuen elektronischen Kommunikationshilfe.

The use of "Komhilf", a newly developed communication aid for persons with severe physical handicap, is described on the example of two patients with amyotrophic lateral sclerosis. Aside individual letter input, it provides input of complete phrases signifying basic needs or common request, without a need for letter-by-letter spelling. After a short familiarization period, both patients were able to communicate up to two to three hours daily via "Komhilf". Psychic stabilization and increased levels of activity were observed in the patients, which subsequently also entailed increased compliance with other therapeutic measures. Additional features include good transportability, use in lying and sitting (wheelchair) patients alike, easy-to-learn operation, and, not least, a competitive price.