[Master trainer concept "structured specialist further education" : A joint project of the German Professional Associations of Internal Medicine, Surgeons and Orthopedic/Trauma Surgeons]. / Mastertrainerkonzept "Strukturierte Facharztweiterbildung" : Ein gemeinsames Projekt der Deutschen Berufsverbände der Internisten, Chirurgen und Orthopäden/Unfallchirurgen.

BACKGROUND: The quality requirements in the practice of postgradual medical further education below the normal level of the further education regulations is a barely developed scientific field in Germany. A systematic use of internationally accepted scientific evidence barely exists. AIM: This research and development project was initiated in 2001 in order to be able to implement a practical but evidence-based model compatible with the existing structure of postgradual medical education. This project has been supported since 2013 by the Professional Associations of Internal Medicine (BDI), Surgeons (BDC) and Orthopedic and Trauma surgeons (BVOU). METHODS: The development phase of this complex intervention was based on three stages involving stakeholder interviews from relevant groups, the identification of a theoretical model for the construction and systematic literature reviews to identify the relevant evidence. RESULTS: The basic model for structured specialist further education developed included the creation and implementation of a simple core curriculum for every department, a tool for systematic feedback within the framework of the annual further education interviews and a simple clinical assessment to evaluate the actual clinical performance of physicians in further education. A pilot test of this model was carried out in 150 specialist departments in Germany and continually developed. DISCUSSION: The project shows that such a program can be systematically developed and pilot studies can be carried out. The central problems in implementation involve the traditional informal further education culture, which as a rule does not implement a systematic elicitation of the state of learning continuously distributed over the whole period of further education and the practical testing of competence development.

[Pain therapy in German long-term care facilities in a European comparison. Results of the SHELTER study]. / Schmerztherapie in deutschen Pflegeeinrichtungen im europäischen Vergleich. Ergebnisse der SHELTER-Studie.

BACKGROUND: A considerable number of nursing home residents suffering from pain are insufficiently treated. International comparisons of pain management in German (GER) and other European (EU) nursing homes are still lacking. OBJECTIVE: This study compared the treatment of pain in GER and EU nursing homes in order to improve allocation of therapeutic resources. MATERIAL AND METHODS: A cross-sectional study was carried out with 4156 residents assessed using the interRAI instrument for long-term care facilities, including pharmacological and non-pharmacological pain management modalities. Only those residents reporting pain were included in the analyses (n = 1900 from EU and 245 from GER). Descriptive analyses and analyses of correlations between different parameters and pain were performed. RESULTS: More than three quarters of the residents with at least moderate pain received pharmacological treatment (GER: 77.4 % and EU: 79.3 %). Combination therapy (pharmacological and non-pharmacological) was more frequent in Germany (approximately 13 %). Even in cases of moderate to severe pain one third of GER compared to one quarter of the EU residents received either no analgesic treatment or only on a when needed basis (PRN). Differences were also seen in drugs used (GER metamizole). The amount of PRN was higher in Germany (approximately 13 %, alone or in combination). Only 5 % received the recommended level of non-pharmacological treatment. Pain severity and decubitus were identified as important triggers for pharmacological treatment. Non-pharmacological treatment was used less often than analgesics (EU: 39.2 %, GER: 46.8 %). There were no differences regarding administration frequency and intensity of non-pharmacological treatments in residents with or without pain; however, non-pharmacological treatment was used less often in residents with successful pharmacological treatment. CONCLUSION: The data demonstrate significant deficits in the recognition and treatment of pain in residents living in German or other European nursing home facilities. Further scope for improvement is seen in better recognition of relevant pain, in the adequate use of PRN and long-term medication and especially in the use of activating non-pharmacological treatment.

Prospective evaluation of renal function, serum vitamin D level, and risk of fall and fracture in community-dwelling elderly subjects.

SUMMARY: This prospective study in elderly showed that kidney function plays a minor role in explaining the high prevalence of vitamin D deficiency seen in noninstitutionalized elderly subjects. However, 25-hydroxyvitamin D levels were clearly inversely associated with risk for first fall, which was especially seen in subjects with calcium levels above median. INTRODUCTION: Few prospective studies in elderly exist that have investigated the association of renal dysfunction and vitamin D status on risk of falls. The aim of this study is to evaluate the association of renal function with 25-hydroxyvitamin D (25-OH-D) levels and, secondly, to assess the role of both factors on the risk of falls and subsequent bone fractures. METHODS: This is a prospective population-based cohort study among noninstitutionalized elderly subjects during a 1-year follow-up. 25-OH-D levels and renal function were estimated, the latter by cystatin C-based equations. Information on falls was assessed prospectively. RESULTS: Overall, 1,385 subjects aged 65 and older were included in the study (mean age 75.6 years), of whom 9.2 % had a 25-OH-D serum level above 75 nmol/L (US units 30 ng/mL); 41.4 %, between 50 and 75 nmol/L (US units 20 to 29 ng/mL, insufficiency); and 49.4 %, <50 nmol/L (US units <20 ng/mL, deficiency). We found no association of chronic kidney disease with risk of first fall. In contrast, 25-OH-D serum categories were clearly associated with risk of first fall and we found evidence of effect modification with calcium levels. In the group with a calcium level above the median (≥ 9.6 mg/dL), subjects with 25-OH-D serum level between 50 and 75 nmol/L and with concentrations <50 nmol/L had a hazard rate ratio (HRR) of 1.75 (1.03-2.87) and 1.93 (1.10-3.37) for risk of first fall. 25-OH-D serum levels were also associated with several markers of inflammation and hemodynamic stress. CONCLUSIONS: We demonstrated an association of 25-OH-D serum levels and risk of first fall, which was especially evident in subjects with serum calcium in upper normal, independent of renal function.

Physical activity and other health-related factors predict health care utilisation in older adults: the ActiFE Ulm study.

BACKGROUND: Health care utilisation (HCU) can be a useful outcome for estimating costs and patient needs. It can also be used as a surrogate parameter for healthy ageing. The aim of this study was to analyse the associations of formerly described and potentially new parameters influencing health care utilisation in older adults in Germany. PATIENTS AND METHODS: The ActiFE Ulm (Activity and Function in the Elderly in Ulm) study is a population-based study in 1,506 community dwelling older adults aged 65-90 years in Ulm and surrounding areas in southwestern Germany. Between March 2009 and April 2010 a full geriatric assessment was performed including accelerometer-based average daily walking duration, comorbidity, medication, physical and psychological functioning, health care utilisation, sociodemographic factors etc. The association between above named measures and health care utilisation, represented by the number of drugs, the days in hospital and the number of physician contacts over one year was calculated in multiple regression models. Analysis was conducted among subjects with complete information (n = 1,059, mean age 76 years, 55% male). RESULTS: The average number of drugs was 4.5 and over 95% of participants visited a physician at least once a year while still more than 65% contacted their physician more than twice a year. Reduced physical activity, BMI, self-rated health and/or comorbidity and male sex were the best predictors of health care utilisation in community dwelling older adults when looking at both the number of drugs and the number of physician contacts over 12 months together. With regard to single diseases entities the best predictors of both the number of drugs and the number of physician contacts were asthma, chronic obstructive pulmonary disease (COPD)/chronic bronchitis and chronic neurological diseases (mostly Parkinson's disease). The number of drugs was most strongly associated with coronary heart disease, diabetes, and high blood pressure. CONCLUSION: Reduced walking activity, self-rated health and/or comorbidity and male sex are the best predictors of health care utilisation as measured by the number of drugs and number of physician contacts over 12 months. Walking activity could be regarded as the most promising modifiable predictor of HCU in older adults.

[Maintenance of health and relief for caregivers of elderly with dementia by using "initial case management": experiences from the Lighthouse Project on Dementia, Ulm, ULTDEM-study]. / Gesunderhaltung und Entlastung pflegender Angehöriger von Demenzkranken durch ein "initiales Case Management": Erfahrungen aus dem Ulmer Leuchtturmprojekt Demenz (ULTDEM-Studie).

BACKGROUND: When facing the well-known demographic development with an increasing number of people suffering from dementia, there is a need of programmes to support nursing relatives and care at home. Many support services have been established in the past few years but they are rarely used by the relatives and the patients. The purpose of the Lighthouse Project Ulm (ULTDEM Study) was to prove the effectiveness of a single advisory approach in order to provide support services after care level classification and to relieve the burden placed on relatives caring for family members suffering from dementia ("initial case management"). METHODS: The ULTDEM Study is a prospective, open, randomized, controlled, interventional study with different parallel outcome measures (burden of caring, quality of life and mood). After the randomization, the interventional group was given comprehensive, individual advice about available treatment possibilities for dementia patients. Control group participants received standard treatment. Inclusion criteria were application of a care level (0 or 1) as well as dementia diagnosis. All participants (patients/relatives) underwent an initial and a 6 month comprehensive assessment. RESULTS: Our results show that a single advisory approach does not lead to a significant difference in outcome measures in interventional and control groups. Those tendencies described have to be interpreted as clinically not relevant. Although utilization of support services increases, it remains similar in both study groups. A confirmatory interpretation has not been possible due to a lack of adjustment to the findings regarding multiple testing and an insufficient degree of recruitment. Possible causes will be discussed such as premature intervention during the course of the disease, a lack of intervention blinding, recruitment bias and lack of an influence on adherence with regard to the use of support services. IMPLICATIONS: The study demonstrates that there is a substantial information deficit for persons affected by dementia and their relatives. Innovative ways still have to be developed to ensure that this information actually reaches the target audience.

Physical activity for the prevention of cognitive decline: current evidence from observational and controlled studies.

A sedentary life style has been associated with different types of dementia in several cross sectional, longitudinal, and case-controlled studies. However, randomized controlled trials that support this relationship are rare, have rather few participants, and mainly focus on physical (usually aerobic) exercise. The benefit of an increased physical activity (PA) has been mainly demonstrated for the prevention of Alzheimer's disease and vascular dementia, less so for other dementia types such as Lewy body dementia or frontotemporal dementia. The clinical evidence builds on a significant amount of animal research pointing to potential mechanisms as to how PA relates to cognitive function. While most studies have investigated singular interventions, others have studied the combination of both mental and physical activity to improve cognition or delay decline. However, questions remain such as what type and how much PA is beneficial? This review gives an overview of the current evidence on the clinical and epidemiological level and tries to answer these questions.

Standard treatment of female patients with breast cancer decreases substantially for women aged 70 years and older: a German clinical cohort study.

BACKGROUND: Standard treatment of patients with breast cancer decreases with age and older persons are mostly excluded from clinical trials. We hypothesized that non-adherence to treatment guidelines occurs for women aged > or =70 years and changes overall survival (OAS) and disease-free survival (DFS). PATIENTS AND METHODS: We enrolled 1922 women aged > or =50 years with histologically confirmed invasive breast cancer treated at the University of Ulm from 1992 to 2005. Adherence to guidelines and effects on OAS and DFS for women aged > or =70 years was compared with that for younger women (50-69 years). RESULTS: Women >70 years less often received recommended breast-conserving therapy (70-79 years: 74%-83%; >79 years: 54%) than women aged < or =69 years (93%). Non-adherence to the guidelines on radiotherapy (<70 years: 9%; 70-79 years: 14%-27%; >79 years: 60%) and chemotherapy (<70 years: 33%; 70-79 years: 54%-77%; > 79 years: 98%) increased with age. Omission of radiotherapy significantly decreased OAS [< or =69 years: hazard ratio (HR) = 3.29; P <0.0001; > or =70 years: HR = 1.89; P = 0.0005] and DFS (< or =69 years: HR = 3.45; P <0.0001; > or =70 years: HR = 2.14; P <0.0001). OAS and DFS did not differ significantly for adherence to surgery, chemotherapy, or endocrine therapy. CONCLUSION: Our study confirms that substandard treatment increases considerably with age. Omission of radiotherapy had the greatest impact on OAS and DFS in the elderly population.

[Reliability of the abbreviated version of the Late Life Function and Disability Instrument--a meaningful and feasible tool to assess physical function and disability in the elderly]. / Reliabilität der deutschen Kurz-Version des "Late Life Function and Disability Instrument". Ein sinnvoller und praktikabler Fragebogen zur Bestimmung der körperlichen Funktion und Beeinträchtigung älterer Personen.

BACKGROUND: The early assessment of prevalent disability and functional decline is of increasing importance for prevention issues and for the evaluation of change in clinical studies. The assessment of common daily tasks and resulting disability is essential for a complete impression of a patient's capabilities. There are plenty of instruments that cover basic and instrumental activities of daily living by assessing the person's dependence at a specific functional task. However, the early stages of everyday life limitations and functional decline are usually not being captured. In this article we have examined psychometric properties of the German adaptation of the abbreviated "late life function and disability instrument", a promising tool that is capable of capturing early aspects of functional decline and disability. METHODS: Older Caucasian men and women (Median=82 years) with a wide range of functional status (Short Physical Performance Battery: Median=6, Min.=0, Max.=12) completed the abbreviated version of the LLFDI once (n=173). A subgroup was assessed twice to examine interrater (n=13) and intrarater (n=10) reliability. Cognitive and functional status was assessed at baseline. RESULTS: Internal consistency (Cronbach's ) was acceptable for the personal role and social role of the frequency items of the disability component (0.55 to 0.62) and very good for all other parts of the instrument (0.78 to 0.89) without a significant difference when compared for overall cognitive performance or executive function. Test-retest reliability was very good (0.81 to 0.96) and interrater reliability was acceptable to very good (0.62 to 0.96) with only acceptable results for the limitation items of the disability component. The total scores of the two components did not demonstrate significant floor or ceiling effects and the interview lasted on average 17 minutes (range 8 to 35 min). INTERPRETATION: The German adaptation of the abbreviated version of the "Late Life Function and Disability Instrument" has minimal ceiling and floor effects, acceptable to good internal consistency and interrater reliability, and very good test-retest reliability. Hence, it constitutes an excellent alternative to common self-rating instruments for the assessment of functional capacities in everyday activities.