["As Good as it Gets at Home" - Reasons for Institutionalisation in Dementia]. / "Zuhause geht es nicht mehr" - Gründe für den Wechsel ins Pflegeheim bei Demenz.

AIM: What are the reasons for institutionalising community-dwelling persons with dementia? METHOD: A written survey of family caregivers and general practitioners was undertaken. RESULTS: Within 2 years 47 of 351 people with dementia (13%) were institutionalised. The person with dementia was involved in the decision in only 1/3 of the cases. The 3 most common reasons were: ensuring the best possible care, high expenditure of care-giving time at home, deterioration of the health of the care-receiver. CONCLUSIONS: From the ethical point of view the exclusion of the persons with dementia from the decision-making with regard to institutionalisation has to be examined critically. The often given reason of ensuring the best possible care through institutionalisation could be counteracted by the improvement of community-based care.

[Dementia patients and levels of care: do symptoms of the illness affect the grading?]. / Demenzkranke und Pflegestufen: Wirken sich Krankheitssymptome auf die Einstufung aus?

OBJECTIVE: As the levels of care within long-term nursing care regulations are defined according to limitations in performing fundamental activities of daily living, the extent to which medically diagnosed cognitive, emotional and behavioral dementia symptoms are taken into account in the grading, should be investigated. METHOD: 390 patients with mild to moderate dementia from the Mid-Franconia region, were included into the IDA ("Initiative Demenzversorgung in Allgemeinmedizin") study by specially trained general practitioners. The GPs had diagnosed dementia and noted the accompanying signs at baseline. In an interview with the caregiver, the Barthel Index was used to measure the level of help required with fundamental daily tasks. Predictors for grading were set down using logistic regression analysis. RESULTS: Where one accompanying sign is present, about half the patients had not been assigned a grade. Besides the Barthel Index, the presence of agitation and agnosia and the absence of depression are the only independent predictors for grading. All other symptoms, impairment of the executive function, loss of orientation, aphasia, anxiety, sleeplessness, aggressiveness and tendency to wander, have no significant predictive value. CONCLUSION: In the future development of nursing care insurance, the need for nursing care should be redefined using symptoms associated with dementia, particularly sleeplessness, aggressiveness and the tendency to wander as inclusion criteria. This is a prerequisite of improving the care available to dementia patients in the long term and also of expanding relief measures for family caregiver.

[Preventive home visits to the elderly: systematic review of available evidence]. / Präventive Hausbesuche im Alter: eine systematische Bewertung der vorliegenden Evidenz.

The aim of preventive home visits to elderly persons is to reduce mortality, to avoid admissions to nursing homes and hospitals and to improve the functional status and general wellbeing of the elderly. Preventive home visits are rarely a standard service in national health care systems. For over 20 years, controlled randomized studies have been carried out to test their effectiveness. This systematic review evaluates the evidence available on preventive home visits for elderly persons in the context of considerations relating to the incorporation of such a service into the German health care system. Three current systematic reviews (two of them meta-analyses) were identified in a systematic literature survey. They consider a total of 26 studies, most of them RCTs. A further three original controlled studies were identified and evaluated. The original studies were very heterogeneous with respect to goals, target groups, intensity and duration of the home visit programme and with respect to the individuals performing the study (number, profession, qualifications and cooperation). This makes it more difficult to perform a pooled overall evaluation. It was possible to consider mortality, admissions to nursing homes, functional status and psychosocial status as relevant target parameters. The systematic reviews arrive at different assessments of effectiveness. A quantitative, across-studies evaluation demonstrated that preventive home visits to elderly persons were effective both in studies with selected and with unselected inclusion of participants. The second meta-analysis did not confirm this result. Effectiveness here was only demonstrated using stratified analyses which investigated a large number of home visits, the performance of a multidimensional assessment with follow-up visits and the average age and morbidity of participants as relevant influencing factors. However no factor exerted an influence over more than one of the investigated target parameters. The findings thus constitute very unspecific evidence of effectiveness with largely unclear determinants of success. Preventive home visit programmes have been tested in various health systems. Results from controlled (randomised) German studies have not been published to date. The results of studies from other countries have only limited applicability to the conditions in the German health care system because the opportunities for, and extent of, economical and effective improvement in the preventive care of the elderly depend on the standard of care existing in the individual country. The additional value of screening depends on the empirical level of care and not on a given standard. At present the introduction of home visits in Germany cannot be recommended beyond studies. However there appear to be sufficient reasons for controlled studies in Germany which should be carried out in a coordinated way with mutual agreement on concepts.