Combination of Structural MRI and FDG-PET of the Brain Improves Diagnostic Accuracy in Newly Manifested Cognitive Impairment in Geriatric Inpatients.

BACKGROUND: The cause of cognitive impairment in acutely hospitalized geriatric patients is often unclear. The diagnostic process is challenging but important in order to treat potentially life-threatening etiologies or identify underlying neurodegenerative disease. OBJECTIVE: To evaluate the add-on diagnostic value of structural and metabolic neuroimaging in newly manifested cognitive impairment in elderly geriatric inpatients. METHODS: Eighty-one inpatients (55 females, 81.6±5.5 y) without history of cognitive complaints prior to hospitalization were recruited in 10 acute geriatrics clinics. Primary inclusion criterion was a clinical hypothesis of Alzheimer's disease (AD), cerebrovascular disease (CVD), or mixed AD+CVD etiology (MD), which remained uncertain after standard diagnostic workup. Additional procedures performed after enrollment included detailed neuropsychological testing and structural MRI and FDG-PET of the brain. An interdisciplinary expert team established the most probable etiologic diagnosis (non-neurodegenerative, AD, CVD, or MD) integrating all available data. Automatic multimodal classification based on Random Undersampling Boosting was used for rater-independent assessment of the complementary contribution of the additional diagnostic procedures to the etiologic diagnosis. RESULTS: Automatic 4-class classification based on all diagnostic routine standard procedures combined reproduced the etiologic expert diagnosis in 31% of the patients (p = 0.100, chance level 25%). Highest accuracy by a single modality was achieved by MRI or FDG-PET (both 45%, p≤0.001). Integration of all modalities resulted in 76% accuracy (p≤0.001). CONCLUSION: These results indicate substantial improvement of diagnostic accuracy in uncertain de novo cognitive impairment in acutely hospitalized geriatric patients with the integration of structural MRI and brain FDG-PET into the diagnostic process.

Requirements of older adults for a daily use of an internet-based cognitive training platform.

A decline of cognitive abilities is a part of normal human ageing. However, recent research has demonstrated that an enriched environment can have a beneficial impact on cognitive function in old age. Accordingly, mentally and socially active lifestyles are associated with less cognitive decline in old age. Specific interventions such as computerized cognitive training programs for older adults are also known to have a positive effect on the level of cognitive functioning. Therefore, online platforms combining cognitive training with web 2.0 features may yield multiple benefits for older users. However, to date only little research exists on technological acceptance and media use in this age-group especially for cognitively-impaired seniors. Therefore, in order to assess specific preferences and potential barriers of older adults regarding a web-based platform for cognitive training, we conducted qualitative interviews with 12 older adults. Half of the participants were diagnosed with mild cognitive impairment (MCI). Most importantly, our results show that cognitive exercises should incorporate themes and topics older adults are interested in. Additional communication features could serve as ideal methods for increasing user motivation. Furthermore, we derived eight critical requirements of older adults concerning daily use of a web-based cognitive training platform. Implications for future research and development are discussed.

Implementation of a home-based interactive training system for fall prevention: requirements and challenges.

A critical need exists for rehabilitation for improving older adults' physical abilities, especially in the field of fall prevention. Although virtual reality and ambient-assistive technology-based approaches are promising, they are cost intensive and frequently face significant obstacles during the developmental process. The authors of the current article developed a motivational interactive training system for fall prevention and stroke rehabilitation and planned a pilot study to measure its usability, user acceptance, and effect on physical abilities and quality of life. Usability results from a field trial are presented. The purpose of the current article is to describe the technological and organizational problems during the development process and field trial. Recommendations for overcoming these barriers are described. These experiences should be taken into account when planning further field trials with assistive technology and older adults.

Information and communication technologies for promoting and sustaining quality of life, health and self-sufficiency in ageing societies--outcomes of the Lower Saxony Research Network Design of Environments for Ageing (GAL).

Many societies across the world are confronted with demographic changes, usually related to increased life expectancy and, often, relatively low birth rates. Information and communication technologies (ICT) may contribute to adequately support senior citizens in aging societies with respect to quality of life and quality and efficiency of health care processes. For investigating and for providing answers on whether new information and communication technologies can contribute to keeping, or even improving quality of life, health and self-sufficiency in ageing societies through new ways of living and new forms of care, the Lower Saxony Research Network Design of Environments for Ageing (GAL) had been established as a five years research project, running from 2008 to 2013. Ambient-assisted living (AAL) technologies in personal and home environments were especially important. In this article we report on the GAL project, and present some of its major outcomes after five years of research. We report on major challenges and lessons learned in running and organizing such a large, inter- and multidisciplinary project and discuss GAL in the context of related research projects. With respect to research outcomes, we have, for example, learned new knowledge about multimodal and speech-based human-machine-interaction mechanisms for persons with functional restrictions, and identified new methods and developed new algorithms for identifying activities of daily life and detecting acute events, particularly falls. A total of 79 apartments of senior citizens had been equipped with specific "GAL technology", providing new insights into the use of sensor data for smart homes. Major challenges we had to face were to deal constructively with GAL's highly inter- and multidisciplinary aspects, with respect to research into GAL's application scenarios, shifting from theory and lab experimentation to field tests, and the complexity of organizing and, in our view, successfully managing such a large project. Overall it can be stated that, from our point of view, the GAL research network has been run successfully and has achieved its major research objectives. Since we now know much more on how and where to use AAL technologies for new environments of living and new forms of care, a future focus for research can now be outlined for systematically planned studies, scientifically exploring the benefits of AAL technologies for senior citizens, in particular with respect to quality of life and the quality and efficiency of health care.

A prospective field study for sensor-based identification of fall risk in older people with dementia.

OBJECTIVE: Aim of this study was to make a fall prognosis in a cohort of older people with dementia in short-term (2 month), mid-term (4 month) and long-term (8 month) intervals using accelerometry during the subjects' everyday life. METHODS: The study was designed as a longitudinal cohort study. The subjects were recruited from a nursing home and geriatric assessment tests were conducted at baseline. Each subject underwent four visits and was measured at each visit for one week. Gait episodes were detected and gait parameters were extracted from these episodes. These gait parameters were combined with the falls occurred during the study. A decision tree induction method was used to analyze the data. RESULTS: Forty subjects participated in the study, whereby 12 drop-outs were registered. The geriatric assessment tests were unable to distinguish between the groups (AUC < 0.6). The evaluation of the models induced with the decision tree classification showed a rate of correctly classified gait episodes of 88.4% for short-term, 74.8% for mid-term, and 88.5 % for long-term monitoring. DISCUSSION AND CONCLUSIONS: We concluded that it is possible to classify gait episodes of fallers and non-fallers in people with dementia during everyday life using accelerometry.

Physical fitness training in Subacute Stroke (PHYS-STROKE)--study protocol for a randomised controlled trial.

BACKGROUND: Given the rising number of strokes worldwide, and the large number of individuals left with disabilities after stroke, novel strategies to reduce disability, increase functions in the motor and the cognitive domains, and improve quality of life are of major importance. Physical activity is a promising intervention to address these challenges but, as yet, there is no study demonstrating definite outcomes. Our objective is to assess whether additional treatment in the form of physical fitness-based training for patients early after stroke will provide benefits in terms of functional outcomes, in particular gait speed and the Barthel Index (co-primary outcome measures) reflecting activities of daily living (ADL). We will gather secondary functional outcomes as well as mechanistic parameters in an exploratory approach. METHODS/DESIGN: Our phase III randomised controlled trial will recruit 215 adults with moderate to severe limitations of walking and ADL 5 to 45 days after stroke onset. Participants will be stratified for the prognostic variables of "centre", "age", and "stroke severity", and randomly assigned to one of two groups. The interventional group receives physical fitness training delivered as supported or unsupported treadmill training (cardiovascular active aerobic training; five times per week, over 4 weeks; each session 50 minutes; total of 20 additional physical fitness training sessions) in addition to standard rehabilitation treatment. The control intervention consists of relaxation sessions (non-cardiovascular active; five times per week week, over 4 weeks; each session 50 minutes) in addition to standard rehabilitation treatment. Co-primary efficacy endpoints will be gait speed (in m/s, 10 m walk) and the Barthel Index (100 points total) at 3 months post-stroke, compared to baseline measurements. Secondary outcomes include standard measures of quality of life, sleep and mood, cognition, arm function, maximal oxygen uptake, and cardiovascular risk factors including blood pressure, pulse, waist-to-hip ratio, markers of inflammation, immunity and the insulin-glucose pathway, lipid profile, and others. DISCUSSION: The goal of this endpoint-blinded, phase III randomised controlled trial is to provide evidence to guide post-stroke physical fitness-based rehabilitation programmes, and to elucidate the mechanisms underlying this intervention. TRIAL REGISTRATION: Registered in ClinicalTrials.gov with the Identifier NCT01953549.

Mining geriatric assessment data for in-patient fall prediction models and high-risk subgroups.

BACKGROUND: Hospital in-patient falls constitute a prominent problem in terms of costs and consequences. Geriatric institutions are most often affected, and common screening tools cannot predict in-patient falls consistently. Our objectives are to derive comprehensible fall risk classification models from a large data set of geriatric in-patients' assessment data and to evaluate their predictive performance (aim#1), and to identify high-risk subgroups from the data (aim#2). METHODS: A data set of n = 5,176 single in-patient episodes covering 1.5 years of admissions to a geriatric hospital were extracted from the hospital's data base and matched with fall incident reports (n = 493). A classification tree model was induced using the C4.5 algorithm as well as a logistic regression model, and their predictive performance was evaluated. Furthermore, high-risk subgroups were identified from extracted classification rules with a support of more than 100 instances. RESULTS: The classification tree model showed an overall classification accuracy of 66%, with a sensitivity of 55.4%, a specificity of 67.1%, positive and negative predictive values of 15% resp. 93.5%. Five high-risk groups were identified, defined by high age, low Barthel index, cognitive impairment, multi-medication and co-morbidity. CONCLUSIONS: Our results show that a little more than half of the fallers may be identified correctly by our model, but the positive predictive value is too low to be applicable. Non-fallers, on the other hand, may be sorted out with the model quite well. The high-risk subgroups and the risk factors identified (age, low ADL score, cognitive impairment, institutionalization, polypharmacy and co-morbidity) reflect domain knowledge and may be used to screen certain subgroups of patients with a high risk of falling. Classification models derived from a large data set using data mining methods can compete with current dedicated fall risk screening tools, yet lack diagnostic precision. High-risk subgroups may be identified automatically from existing geriatric assessment data, especially when combined with domain knowledge in a hybrid classification model. Further work is necessary to validate our approach in a controlled prospective setting.

Comparison of four different mobile devices for measuring heart rate and ECG with respect to aspects of usability and acceptance by older people.

In the area of product design and usability, most products are developed for the mass-market by technically oriented designers and developers for use by persons who themselves are also technically adept by today's standards. The demands of older people are commonly not given sufficient consideration within the early developmental process. In the present study, the usability and acceptability of four different devices meant to be worn for the measurement of heart rate or ECG were analyzed on the basis of qualitative subjective user ratings and structured interviews of twelve older participants. The data suggest that there was a relatively high acceptance concerning these belts by older adults but none of the four harnesses was completely usable. Especially problematic to the point of limiting satisfaction among older subjects were problems encountered while adjusting the length of the belt and/or closing the locking mechanism. The two devices intended for dedicated heart rate recording yielded the highest user ratings for design, and were clearly preferred for extended wearing time. Yet for all the devices participants identified several important deficiencies in their design, as well as suggestions for improvement. We conclude that the creation of an acceptable monitoring device for older persons requires designers and developers to consider the special demands and abilities of the target group.

[The effect of medications on the risk of falling in elderly patients]. / Der Einfluss von Arzneimitteln auf das Sturzrisiko älterer Patienten.

In advanced age, the tendency to fall increases, as does the severity of the over, falls cause substantial costs to the health and welfare systems. Among elderly people, most falls result from the concurrence of several risk factors and a trigger. Taking medication can significantly influence the tendency to fall. Adverse drug reactions such as hypotension or the inhibition of motor or cognitive skills are often the cause of falling. In each case it must be determined whether the use of a medication is solely an indicator of a functional disorder or acts as an independent risk factor for falling. Pharmacists can help reduce the risk of falling by advising elderly patients on a medication's side effects and its interaction with other medications as well as on additional risk factors.

The Lower Saxony research network design of environments for ageing: towards interdisciplinary research on information and communication technologies in ageing societies.

Worldwide, ageing societies are bringing challenges for independent living and healthcare. Health-enabling technologies for pervasive healthcare and sensor-enhanced health information systems offer new opportunities for care. In order to identify, implement and assess such new information and communication technologies (ICT) the 'Lower Saxony Research Network Design of Environments for Ageing' (GAL) has been launched in 2008 as interdisciplinary research project. In this publication, we inform about the goals and structure of GAL, including first outcomes, as well as to discuss the potentials and possible barriers of such highly interdisciplinary research projects in the field of health-enabling technologies for pervasive healthcare. Although GAL's high interdisciplinarity at the beginning slowed down the speed of research progress, we can now work on problems, which can hardly be solved by one or few disciplines alone. Interdisciplinary research projects on ICT in ageing societies are needed and recommended.

Defining the user requirements for wearable and optical fall prediction and fall detection devices for home use.

One of the major problems in the development of information and communication technologies for older adults is user acceptance. Here we describe the results of focus group discussions that were conducted with older adults and their relatives to guide the development of assistive devices for fall detection and fall prevention. The aim was to determine the ergonomic and functional requirements of such devices and to include these requirements in a user-centered development process. A semi-structured interview format based on an interview guide was used to conduct three focus group discussions with 22 participants. The average age was 75 years in the first group, 68 years in the second group and 50 years in the third group (relatives). Overall, participants considered a fall prediction system to be as important as a fall detection system. Although the ambient, unobtrusive character of the optical sensor system was appreciated, wearable inertial sensors were preferred because of their wide range of use, which provides higher levels of security. Security and mobility were two major reasons for people at risk of falling to buy a wearable and/or optical fall prediction and fall detection device. Design specifications should include a wearable, non-stigmatising sensor at the user's wrist, with an emergency option in case of falling.

Parenteral nutrition support for patients with pancreatic cancer. Results of a phase II study.

BACKGROUND: Cachexia is a common problem in patients (pts) suffering from upper gastrointestinal cancer. In addition, most of these patients suffer from malabsorption and stenosis of the gastrointestinal tract due to their illness. Various methods of supplementary nutrition (enteral, parenteral) are practised. In patients with advanced pancreatic cancer (APC), phase angle, determined by bio-electrical impedance analysis (BIA), seems to be a survival predictor. The positive influence of BIA determinate predictors by additional nutrition is currently under discussion. METHODS: To examine the impact of additional parenteral nutrition (APN) we assessed outpatients suffering from APC and progressive cachexia. The assessment based on the BIA method. Assessment parameters were phase angle, ECM/BCM index (ratio of extracellular mass to body cell mass), and BMI (body mass index). Patients suffering from progressive weight loss in spite of additional enteral nutritional support were eligible for the study. RESULTS: Median treatment duration in 32 pts was 18 [8-35] weeks. Response evaluation showed a benefit in 27 pts (84%) in at least one parameter. 14 pts (43.7%) improved or stabilised in all three parameters. The median ECM/BCM index was 1.7 [1.11-3.14] at start of APN and improved down to 1.5 [1.12-3.36] during therapy. The median BMI increased from 19.7 [14.4-25.9] to 20.5 [15.4-25.0]. The median phase angle improved by 10% from 3.6 [2.3-5.1] to 3.9 [2.2-5.1]. CONCLUSIONS: We demonstrated the positive impact of APN on the assessed parameters, first of all the phase angle, and we observed at least a temporary benefit or stabilisation of the nutritional status in the majority of the investigated patients. Based on these findings we are currently investigating the impact of APN on survival in a larger patient cohort. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00919659.