[Duplication of hospitalizations of nursing home residents from 2007 to 2009--a retrospective analysis]. / Verdoppelung der Hospitalisationen von Pflegeheimpatienten von 2007 bis 2009 - eine retrospektive Analyse.

AIM: To demonstrate why the number of hospitalizations of nursing home residents has doubled although several studies have established that hospitalizations do not diminish their mortality rate. METHODS: Retrospective analysis of medical databasis from 815 patients of the eight nursing homes of Zürich, thereof 180 were hospitalized in 2007, 234 in 2008 and 401 in 2009. The reasons for a hospitalization have been classified in nine categories. RESULTS: The category "fall with fractures" with a proportion of 29% contributes most to the augmentation of hospitalizations, followed by the categories "ambiguous condition" with 24% and "improving quality of life" with 17%. Hospitalizations for the sustained optimization of quality of life explain 62% of the increased hospitalization rate. CONCLUSION: Nursing home residents are not hospitalized to keep them longer alive, but to optimize their quality of life.

[Polypharmacy is an indicator for a poor prognosis, which is not altered by deprescribing in nursing home]. / Polypharmazie ist ein Indikator für kurze Überlebensdauer im Pflegeheim - Daran ändert das Absetzen von Medikamenten nichts.

AIM: To examine the influence of polypharmacy ordered by the pretreating site and deprescribing (i.e. the appropriate withdrawal of prescribed drugs) by the nursing home physician on survival time. METHODS: Retrospective Analysis of medical databasis from 1,249 patients, thereof 611 in a nursing home with practice of deprescribing. RESULTS: 70% of the patients with excessive polypharmacy (>9 drugs), 57% of those with polypharmacy (6 to 9 drugs) and 43% of the remaining patients (<6 drugs) deceased within 286 days after admission (chi-squared 2 DF = 43.72; p <0.001). Deprescribing by the nursing home physician at admission revealed no influence on survival time. CONCLUSION: Polypharmacy is not the reason, but an indicator for a poor prognosis, which is not altered by deprescribing.

[Should assistance to suicide be allowed in a case of chronic persistent depression in a nursing home patient]. / Suizidbeihilfe bei chronischer, therapierefraktärer Depression im Pflegeheim?

A 75 years old widower suffered since 26 years of many episodes of recurrent depressions. A compensated diabetes and a chronic, slowly progressive sensory-motor Neuropathy are relevant somatic comorbidities. Because of anxiety attacks complicating his progressively severe depression he could not be cared adequately in the old people home he lived in and was hospitalised. The anxiety responded well to Benzodiazepines, but the severe depression persisted despite a pharmacotherapy with Lithium, Mianserin and Citalopran. He was therefore transferred into a nursing home. There he demanded - supported by his son - an assisted suicide. 2 psychiatrists judged his wish to die as independent to his actual depression, a geronto-psychiatrist judged his suicidal ideas as a typical symptom of depression. Therefore the demanded assisted suicide was not allowed in the nursing home according to communal legal rules not allowing assisted suicide of persons with psychiatric illness in communal institutions. A hospitalisation against his own and his son's will was however not done and the assisted suicide was executed in privacy. This in Switzerland is legal even in cases of severe chronic psychiatric illness without a terminal disease.

[Basics of gerontopharmaceutic therapy and the therapy of agitation in old age]. / Pharmakotherapie für Alterspatienten. Allgemeine Grundsätze und die Behandlung der Agitiertheit im Speziellen.

The biggest problem of gerontopharmaceutic therapy is polypharmacy, because it potentiates side effects and malcompliance. Best practice today includes instruction of long time patients in medication self management, which includes regular use of detailed taken medication lists. In gerontopharmaceutic therapy the following substances should be avoided: anticholinergics, dopamin receptor stimulants, long acting oral antidiabetics, benzodiazepine (other then for substitution in low dose dependency, in anaesthesia or in palliative situations) and neuroleptics (other then for psychotic symptoms). In unspecific agitation with or without dementia the measure of first choice is adaption of the milieu, which may be supported by the prescription of a sedative non tricyclic antidepressive medication.

[Cognitive impairment not due to dementia]. / Nicht jede Hirnleistungsschwäche ist demenzbedingt.

A 55 years old woman lived with the parents until they died. Recently, she refused to open her apartment for necessary repairs. An examination was possible only after police opened the apartment. She is in excellent physical health, has intact memory functions but reduced executive abilities. She has no delusion, but excessive fear from strangers as taught by her parents. The clinical impression of a debility is confirmed by enquiry at her relatives. The installation of a guardianship can give the necessary support for daily life.

[The physicians role in a quarreling family of a demented patriarch]. / Zwischen den Fronten einer zerstrittenen Familie. Ein geriatrischer Hausbesuch.

The physician of a demented patient whose wealth is disputed by two fractions of his quarreling familiy had to examine his power of judgement and his ability to controll authorized persons. The courts up to the supreme court of Switzerland based their decisions on the physisians findings. Physicians have to base their opinion on carefull examination of the patients mental ability to understand and reason the contested issues.

Anti-mycobacterial therapy in Crohn's disease heals mucosa with longitudinal scars.

BACKGROUND: A possible causative link between Crohn's disease and Mycobacterium avium ss paratuberculosis has been suggested. AIM: To report unique scarring in Crohn's disease patients treated with anti-Mycobacterium avium ss paratuberculosis therapy. PATIENTS: A retrospective review of 52 patients with severe Crohn's disease was conducted. Thirty-nine patients who had at least one follow-up colonoscopy during treatment were included. METHODS: Patients received rifabutin (up to 600 mg/day), clofazimine (up to 100 mg/day) and clarithromycin (up to 1 g/day) - anti-Mycobacterium avium ss paratuberculosis therapy - for 6 months to 9 years. Ramp-up dosing was used. Colonoscopies and histological analyses monitored progress. RESULTS: Twenty-two patients (56.4%, 22/39) healed with unusual scarring, which appeared as branched, ribbon-like, elevated lines. In 2/6 patients (33.3%) who had > 3 years of treatment after scarring occurred, scars receded, becoming imperceptible as full healing occurred. Histologically, a marked reduction in inflammation occurred in 15/39 patients (38.5%). Of these, 6/15 patients (40%) displayed restoration of normal mucosa. Longitudinal scarring occurred in 12/15 patients (80%) with improved histology. CONCLUSIONS: The presence of scarring fading to normal mucosa on anti-MAP therapy implies a more profound healing not seen with standard anti-inflammatory and immunosuppressant drugs. Longitudinal scarring and consequent healing with normal histology should become a standard treatment goal for Crohn's disease.

Molecular evidence for Mycobacterium avium subspecies paratuberculosis (MAP) in Crohn's disease correlates with enhanced TNF-alpha secretion.

BACKGROUND: Support for a role of Mycobacterium avium subspecies paratuberculosis in Crohn's disease is largely based on epidemiological evidence, as no data on mechanisms linking the presence of M. avium subspecies paratuberculosis with gut damage is available. AIMS: To determine whether the presence of M. avium subspecies paratuberculosis contributes to the pathogenesis of Crohn's disease by promoting cytokine secretion within gut mucosa. PATIENTS AND METHODS: A total of 235 subjects were recruited: 63 with Crohn's disease, 53 with ulcerative colitis, 45 with irritable bowel syndrome and 74 normal controls. M. avium subspecies paratuberculosis status was defined by nested PCR using IS900 sequence. Gut mucosal organ cultures were established to detect cytokine secretion patterns. RESULTS: Significantly higher tumour necrosis factor-alpha concentrations were found in culture supernatants for Crohn's disease compared to ulcerative colitis (p<0.05), irritable bowel syndrome (p<0.01) and controls (p<0.0001). When tumour necrosis factor-alpha levels were correlated with the presence of M. avium subspecies paratuberculosis, significantly greater concentrations were only found in M. avium subspecies paratuberculosis-positive Crohn's disease patients (p<0.05). Tumour necrosis factor-alpha levels in M. avium subspecies paratuberculosis-positive Crohn's disease were significantly higher than in M. avium subspecies paratuberculosis-positive ulcerative colitis (p<0.01), M. avium subspecies paratuberculosis-positive irritable bowel syndrome (p<0.05) and M. avium subspecies paratuberculosis-positive controls (p<0.01) and all M. avium subspecies paratuberculosis-negative specimens. CONCLUSIONS: The data link M. avium subspecies paratuberculosis with a pathogenic mechanism in Crohn's disease and is consistent with abnormal macrophage handling of M. avium subspecies paratuberculosis.

Caregivers' adaptation to change: the impact of increasing impairment of persons suffering from dementia on their caregivers' subjective well-being.

As progressive dementia involves changes in patients' behaviour and cognitive and functional abilities, dementia caregiving can be considered as a process that demands continuous adaptation to change. The current intervention study investigated associations between the course of dementia patients' impairment and their caregivers' well-being over two years. One hundred and twenty-eight care recipient-caregiver dyads participated in a controlled randomised intervention study (psycho-educational group intervention), 99 dyads in which the care recipients still lived at home participated in the second assessment, and 75 dyads in the third assessment. Caregivers were interviewed about their subjective well-being (emotional well-being and life satisfaction) as well as care recipients' behavioural problems and functional disability. Care recipients completed various neuropsychological tests. The assessments were repeated one and two years later. The psycho-educational intervention had a positive impact on caregivers' well-being. Level and increase in behavioural problems and increases in cognitive and functional impairment negatively affected caregiver well-being over time. For participants from the control condition the negative association between increase in impairment and decrease in caregiver well-being over time was stronger than for the caregivers in the intervention group. Our results suggest that it is not only the severity of current problems and stress, but also the rate of change, that is important for caregivers' well-being. Psycho-educational group intervention may help caregivers to adapt to the increasing impairment of care recipients with dementia.

Efficacy and safety of rifabutin-containing 'rescue therapy' for resistant Helicobacter pylori infection.

BACKGROUND: Current 'rescue' therapies provide inadequate Helicobacter pylori eradication rates because of antibiotic resistance. AIM: To test the efficacy of a modified triple regimen combining rifabutin, pantoprazole and amoxicillin as rescue therapy for patients in whom eradication of H. pylori had failed standard clarithromycin-based triple therapy. METHODS: One hundred and thirty patients (mean age 51.7 +/- 14.8 years) who had failed one or more eradication attempts with omeprazole, clarithromycin and amoxicillin were treated for 12 days with rifabutin 150 mg daily, amoxicillin 1 g or 1.5 g t.d.s, and pantoprazole 80 mg t.d.s. RESULTS: The intention-to-treat and per-protocol eradication rates were 90.8/90.8%. Metronidazole or/and clarithromycin resistance had no significant impact on H. pylori eradication rates. A higher overall eradication rate of 96.6% (95% CI: 92.1-101%) was obtained in patients treated with a regimen containing 1.5 g amoxicillin t.d.s compared with 90.7% (95% CI: 82-98.6%) using a regimen with 1 g amoxicillin t.d.s but the difference was not significant. Side-effects reported in 40% of patients were mild. CONCLUSION: A 12-day course of low dose of rifabutin with an increased dose of amoxicillin and pantoprazole is well-tolerated and highly effective against dual-resistant H. pylori infection after failure of triple therapy.

[Does a reduction of drugs yield a higher quality of life in geriatric patients?]. / Bessere Lebensqualität geriatrischer Patienten durch weniger Medikamente?

Considering the constant increase of medication costs in medical institutions we analysed in a Swiss municipal nursing home whether medication in geriatric long term patients can be reduced without compromising quality of life. To document these effects we applied two established questionnaires on different issues of quality of life; the interviews with the patients and with the nursing staff were performed as a pre-post-comparison of the 3-month intervention. The new geriatric medication concept allowed a decreased daily medication as well as a 23% reduction of the medication costs at an average. In comparison to a previous group of control this study showed no reduction in quality of life for nursing home residents but even a stabilisation yielding to an actual improvement of quality of life.

[Can falls in nursing homes be avoided?]. / Sind Stürze in Langzeitpflegeeinrichtungen vermeidbar?

Fall-related injuries in nursing homes for the aged are frequent and cost-intensive. Their iatrogenic causes are well known and avoided in modern geriatric institutions. We examined all falls in an institution during the period of 19 months. Patients who carry out daily tasks on a semi-independent level were most at risk. The main risk-factor was dementia. Medication did not prove a major risk-factor. At 37% p. a. the risk of falling was lower than in previous studies. This was due to a restriction on benzodiazepines with short term effects, minimising of neuroleptics, diuretics and other types of antihypertensives as well as avoidance of polypharmacy. Unavoidable risks need to be identified and should result in use of a hip protector.

[Can empowerment of elderly with chronic disease be achieved in Switzerland? First results of the ALLFIT program in Zurich]. / Ist Empowerment chronisch kranker Betagter in der Schweiz möglich? Erste Resultate des Zürcher ALLFIT-Programms.

Self management courses can efficiently empower elderly with chronic disease. ALLFIT, a Swiss self management and fitness programme for seniors with chronic heart, lung, musculoskeletal or diabetic disease, consists of individual contracting and coaching by a Nurse, a weekly Fitness Training and 8 self management courses for 2 hours a week. Of the first 100 Participants, 99 defined contracts of goals and 80 achieved at least partially, 21% improved their physical fitness in walking and 25% in climbing stairs. Empowerment of elderly with chronic diseases can be achieved in Switzerland by a combination of fitness, self management training and individual coaching.

[How stable is the attitude of aged people towards life-extending measures? Results of a 3-year follow-up in nursing home residents]. / Wie stabil ist die Einstellung Betagter zu lebensverlängernden Massnahmen? Resultate einer 3-Jahres-Katamnese von Pflegeheimbewohnern.

OBJECTIVE: To explore the stability of attitude towards life-extending measures in aged people. METHOD: Face-to-face interviews of nursing home residents at an interval of 3 years (prospective longitudinal survey). RESULTS: During the first interview period in 1997 (n=50), 19 nursing home residents (38%) had advocated treatment with antibiotics in a hypothetical scenario of acute life-threatening pneumonia. 15 individuals (30%) had refused such treatment, while statements from a further 16 (32%) had been ambivalent. Three years later, 19 individuals could be re-interviewed (28 had died in the meantime, 3 suffered from advanced dementia). 16 of these expressed the same or a similar attitude towards the above scenario as they did three years earlier (correspondence 84.2%, p<0.01). CONCLUSION: The results indicate a high stability of attitude towards life-extending measures in aged people. This finding may have implications for the meaning of advance directives in geriatric long-term care.

[Effects of social support on well-being of demented nursing home residents. The Käferberg Visitation Study]. / Die Auswirkungen sozialer Unterstützung auf das Wohlbefinden dementer Heimbewohnerinnen und Heimbewohner. Die Käferberg-Besucherstudie.

BACKGROUND: Relatives and caregivers of patients with dementia are often insecure about the impact of their efforts. This study examines whether and to what extent social support in the form of regular visits is increasing the well-being of demented aged. PROCEDURE: A field experiment with slightly to seriously demented institutionalized aged persons (MMS 5-25) was carried out to assess the effect of increased social support upon their well-being. Voluntary helpers, who were willing to visit their patients on a regular basis, were recruited by appeals at the senior university and by advertisements. The volunteers were trained to deal with the demented and were looked after regularly. The test subjects were randomly assigned to one of two test groups. The first group was visited regularly for ten weeks, whereas the second group served as a control group. The participants of the experimental group received a visiting card with a photo of the volunteer and the next appointment date to remember their visitors and to increase the effect of predictability. RESULTS: The effect of visits on the well-being of the institutionalized aged persons was significantly positive (F(1,39) = 11.16, p < 0.002). The psychological, physiological and social well-being of the participants was improved. Additionally, visits moderated the pain resulting from physical illness and seemed to decrease the effects of mental decline on their performance. Furthermore, it was most impressive to find that the demented aged really took notice of the visits and seemed to remember them in one way or an other. The study pointed out that demented aged persons are still very sensitive in an emotional respect and that they are still able to give astonishing good and differentiated information about their feelings even in an advanced state of dementia. Even the volunteers gained from their visits, which was shown by their higher well-being after their visits.