A randomised trial of a geriatric evaluation and management consultation services in frail hospitalised patients.

BACKGROUND: the usefulness of geriatric evaluation and management (GEM) approaches in the care of frail elderly patients remains uncertain. We examined whether an inpatient geriatric consultation service might be beneficial in a country with a social welfare system. METHODS: we conducted a randomised trial with 345 patients from five centres. Ninety additional patients from four separate centres without GEM teams served as an external comparison. All patients were hospitalised, at least 65 years and frail. Patients were randomly assigned to either comprehensive geriatric assessment and management in the form of consultations and follow-up or usual care. Primary outcomes were rehospitalisation and nursing home placement 1 year after randomisation. Secondary outcomes were survival, functional, emotional and cognitive status, social situation and quality of life. FINDINGS: at 12 months, the groups did not differ in the rate of rehospitalisation (intervention 67%, control 60%, P=0.30), nursing home placement (intervention 19%, control 14%, P=0.27), survival (intervention 81%, control 85%, P=0.56) or any of the other secondary measures. The external comparison groups were also similar in nursing home placement (16%, P=0.40), survival (80%, P=0.88) and all the secondary variables, but rehospitalisation was less (48%, P=0.04). No subgroup benefited from the intervention. INTERPRETATION: care provided by consultation teams did not improve the rates of rehospitalisation or nursing home placement. This is not due to carry-over effects of geriatric knowledge into the control group.

Direct comparison of total sleep deprivation and late partial sleep deprivation in the treatment of major depression.

BACKGROUND: There are clinical as well as experimental indications that--contrary to what is generally assumed--late partial sleep deprivation (LPSD) is not as effective as total sleep deprivation (TSD) in the treatment of depression. METHOD: We conducted a randomised balanced crossover study with 39 in-patients with major depression (mainly unipolar) in which both procedures LPSD and TSD were compared within a 1-week interval. Response was defined as a reduction of > or =30% in the 6-item Hamilton Depression Rating Scale and/or one of two self-rating scales (Adjective Mood Scale, Visual Analogue Scale). RESULTS: Overall response rate on the day after was low (0-53%, depending on the rating used). TSD proved slightly and in about half of the comparisons also significantly more effective than LPSD. In general, first treatments were more effective than second treatments; there were 10-20% second day responses; in up to 10% of the treatments patients worsened after sleep deprivation (using the same absolute criteria as for therapeutic response). LIMITATIONS: Non-blind rating, intentional and unintentional napping (microsleep) was not recorded, mainly unipolar depressives. CONCLUSIONS: Total sleep deprivation seems to be more effective than late partial sleep deprivation. We believe that there might be a dose-response relationship between hours of lost sleep and therapeutic effect within the range of 1 night.

Treatment with simvastatin in normocholesterolemic patients with Alzheimer's disease: A 26-week randomized, placebo-controlled, double-blind trial.

In a randomized, placebo-controlled, double-blind study, we investigated whether statins alter cholesterol metabolites and reduce Abeta levels in the cerebrospinal fluid of 44 patients with Alzheimer's disease. Individuals were given up to 80mg simvastatin daily or placebo for 26 weeks. Overall, simvastatin did not significantly alter cerebrospinal fluid levels of Abeta40 and Abeta42. In post hoc analysis, simvastatin significantly decreased Abeta40 levels in the cerebrospinal fluid of patients with mild Alzheimer's disease. The reduction of Abeta40 correlated with the reduction of 24S-hydroxycholesterol. These changes were not observed in more severely affected patients.

[The Tübingen questionnaire of treatment satisfaction]. / Der Tübinger Bogen zur Behandlungszufriedenheit (TUBB 2000) - Ein Instrument zur Qualitätsentwicklung in psychiatrischen Kliniken -

OBJECTIVE: Development of an instrument to assess patient satisfaction with inpatient psychiatric treatment as one component of quality of care. METHODS AND RESULTS: The TUBB 2000 has been developed in four steps (n = 80; n = 111; n = 104; n = 135) and covers the inpatients' satisfaction with 22 areas of psychiatric care. Three factors were extracted: "atmosphere", "quality of treatment", "autonomy". The relationship to the therapeutic staff was especially important for the patients. Intervention variables had no significant impact on patients' satisfaction. Answers to change oriented questions have been less variable than to a state oriented questions. CONCLUSION: The construct patients' satisfaction implies many methodological pitfalls. The TUBB 2000 can provide useful change sensitive data of patients' satisfaction with the quality of care in a psychiatric unit. It may help to increase quality of inpatient care in psychiatry.

Therapeutic use of sleep deprivation in depression.

Total sleep deprivation (TSD) for one whole night improves depressive symptoms in 40-60% of treatments. The degree of clinical change spans a continuum from complete remission to worsening (in 2-7%). Other side effects are sleepiness and (hypo-) mania. Sleep deprivation (SD) response shows up in the SD night or on the following day. Ten to 15% of patients respond after recovery sleep only. After recovery sleep 50-80% of day 1 responders suffer a complete or partial relapse; but improvement can last for weeks. Sleep seems to lead to relapse although this is not necessarily the case. Treatment effects may be stabilised by antidepressant drugs, lithium, shifting of sleep time or light therapy. The best predictor of a therapeutic effect is a large variability of mood. Current opinion is that partial sleep deprivation (PSD) in the second half of the night is equally effective as TSD. There are, however, indications that TSD is superior. Early PSD (i.e. sleeping between 3:00 and 6:00) has the same effect as late PSD given equal sleep duration. New data cast doubt on the time-honoured conviction that REM sleep deprivation is more effective than non-REM SD. Both may work by reducing total sleep time. SD is an unspecific therapy. The main indication is the depressive syndrome. Some studies show positive effects in Parkinson's disease. It is still unknown how sleep deprivation works.