Who Benefited the Most? Effectiveness of a Lifestyle Intervention Against Cognitive Decline in Older Women and Men - Secondary Analysis of the AgeWell.de-trial.

INTRODUCTION: Differences between women and men matter in the prevalence and risk factors of dementia. We aimed to examine potential sex differences regarding the effectiveness by running a secondary analysis of the AgeWell.de trial, a cluster-randomized multicenter multi-domain lifestyle intervention to reduce cognitive decline. METHODS: Intention-to-treat analyses of women (n=433) and men (n=386) aged 60 to 77 years were used for models including interactions between intervention group allocation and sex followed by subgroup analysis stratified by sex on primary and secondary outcomes. Further, the same procedure was repeated for age groups (60-69 vs. 70-77) within sex-specific subgroups to assess the effectiveness in different age groups. TRIAL REGISTRATION: German Clinical Trials Register (ref. number: DRKS00013555). RESULTS: No differences were found between women and men in the effectiveness of the intervention on cognitive performance. However, women benefitted from the intervention regarding depressive symptoms while men did not. Health-related quality of life was enhanced for younger intervention participants (60-69 years) in both women and men. CONCLUSION: The AgeWell.de intervention was able to improve depressive symptoms in women and health-related quality of life in younger participants. Female participants between 60 and 69 years benefited the most. Results support the need of better individually targeted lifestyle interventions for older adults.

Better care for less money: cost-effectiveness of integrated care in multi-episode patients with severe psychosis.

OBJECTIVE: To compare cost-effectiveness of integrated care with therapeutic assertive community treatment (IC-TACT) versus standard care (SC) in multiple-episode psychosis. METHOD: Twelve-month IC-TACT in patients with schizophrenia-spectrum and bipolar I disorders were compared with a historical control group. Primary outcomes were entropy-balanced cost-effectiveness based on mental healthcare costs from a payers' perspective and quality-adjusted life years (QALYs) as a measure of health effects during 12-month follow-up. RESULTS: At baseline, patients in IC-TACT (n = 214) had significantly higher illness severity and lower functioning than SC (n = 56). Over 12 months, IC-TACT had significantly lower days in inpatient (10.3 ± 20.5 vs. 28.2 ± 44.9; P = 0.005) and day-clinic care (2.6 ± 16.7 vs. 16.4 ± 33.7; P = 0.004) and correspondingly lower costs (€-55 084). Within outpatient care, IC-TACT displayed a higher number of treatment contacts (116.3 ± 45.3 vs. 15.6 ± 6.3) and higher related costs (€+1417). Both resulted in lower total costs in IC-TACT (mean difference = €-13 248 ± 2975, P < 0.001). Adjusted incremental QALYs were significantly higher for IC-TACT versus SC (+0.10 ± 0.37, P = 0.05). The probability of cost-effectiveness of IC-TACT was constantly higher than 99%. CONCLUSION: IC-TACT was cost-effective compared with SC. The use of prima facies 'costly' TACT teams is highly recommended to improve outcomes and save total cost for patients with severe psychotic disorders.

Longitudinal Analysis of Outpatient Physician Visits in the Oldest Old: Results of the AgeQualiDe Prospective Cohort Study.

OBJECTIVES: The aim of this study was to identify determinants of outpatient health care utilization among the oldest old in Germany longitudinally. DESIGN: Multicenter prospective cohort "Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe). SETTING: Individuals in very old age were recruited via GP offices at six study centers in Germany. The course of outpatient health care was observed over 10 months (two waves). PARTICIPANTS: Primary care patients aged 85 years and over (at baseline: n=861, with mean age of 89.0 years±2.9 years; 85-100 years). MEASUREMENTS: Self-reported numbers of outpatient visits to general practitioners (GP) and specialists in the past three months were used as dependent variables. Widely used scales were used to quantify explanatory variables (e.g., Geriatric Depression Scale, Instrumental Activities of Daily Living Scale, or Global Deterioration Scale). RESULTS: Fixed effects regressions showed that increases in GP visits were associated with increases in cognitive impairment, whereas they were not associated with changes in marital status, functional decline, increasing number of chronic conditions, increasing age, and changes in social network. Increases in specialist visits were not associated with changes in the explanatory variables. CONCLUSION: Our findings underline the importance of cognitive impairment for GP visits. Creating strategies to postpone cognitive decline might be beneficial for the health care system.

[Informal care for dementia according to type of service]. / Informelle Pflege bei Demenz nach Leistungsarten.

BACKGROUND: Dementia is a major challenge for society and its impact will grow in the future. Informal care is an essential part of dementia care. Previous studies considered informal care as a whole and not by its components. OBJECTIVE: We aimed to assess the degree of association between specific informal care services and dementia. MATERIAL AND METHODS: This analysis is based on data from the seventh wave of the AgeCoDe/AgeQualiDe study. Dementia was diagnosed based on the DSM-IV criteria. Severity of dementia was assessed and categorized by means of the Clinical Dementia Rating and eight individual informal care services were considered. Logistic regression models were used to assess associations. RESULTS: Of the 864 participants 18% suffered from dementia (very mild: 4%; mild: 6%; moderate: 5%; severe: 3%). All informal care services were significantly associated with dementia, with an emphasis on "supervision", "regulation of financial matters" and "assistance in the intake of medication". Considering different degrees of dementia severity, similar results arose from the analyses. All three aforementioned services showed a pronounced association with all degrees of dementia severity, except for supervision and very mild dementia. CONCLUSION: The provision of all types of informal care services is associated with dementia. The association is pronounced for services that can be more easily integrated into the daily routines of the informal caregiver. Policy makers who plan to integrate informal care into the general care arrangements for dementia should consider this.

Does Visual Impairment Affect Social Ties in Late Life? Findings of a Multicenter Prospective Cohort Study in Germany.

OBJECTIVE: To investigate how visual impairment affects social ties in late life longitudinally. DESIGN: Population-based prospective cohort study. SETTING: Individuals in old age were recruited via general practitioners' offices (at six study centers) in Germany. They were interviewed every 18 months. PARTICIPANTS: Individuals aged 75 years and above at baseline. Follow-up wave 2 (36 months after baseline, n=2,443) and wave 4 (72 months after baseline, n=1,618) were used for the analyses presented here. MEASUREMENTS: Social ties were assessed using the 14-item form of the questionnaire for social support (F-SozU K-14). Visual impairment was self-rated on a three level Likert scale (no impairment, mild visual impairment, or severe/profound visual impairment). RESULTS: Adjusting for sociodemographic factors, hearing impairment and comorbidity, fixed effects regressions revealed that the onset of mild visual impairment decreased the social support score, in particular the emotional support score. Additionally, the onset of mild hearing impairment decreased the social support score in men. Moreover, increasing age decreased the social support score in the total sample and in both sexes. Loss of spouse and increasing comorbidity did not affect the social support score. CONCLUSION: Our results highlight the importance of visual impairment for social ties in late life. Consequently, appropriate strategies in order to delay visual impairment might help to maintain social ties in old age.

Factors Affecting Functional Impairment among Elderly Germans - Results of a Longitudinal Study.

OBJECTIVE: To investigate causal factors of functional impairment in old age in a longitudinal approach. DESIGN: A population-based prospective cohort study. SETTING: Elderly individuals were recruited via GP offices at six study centers in Germany. They were observed every 1.5 years over six waves. PARTICIPANTS: Three thousand two hundred fifty-six people aged 75 years and older at baseline. MEASUREMENTS: Functional impairment was quantified by the Lawton and Brody Instrumental Activities of Daily Living scale (IADL) and the Barthel-Index (BI). RESULTS: Fixed effects regressions revealed that functional impairment (IADL; BI) increased significantly with ageing (ß=-.2; ß=-1.1), loss of a spouse (ß= .5; ß=-3.1), not living alone in private household (ß=-1.2; ß=-5.5), depression (solely significant for IADL: ß= .6) and dementia (ß=-2.3; ß=-18.2). The comorbidity score did not affect functional impairment. CONCLUSION: Our findings underline the relevance of changes in sociodemographic variables as well as the occurrence of depression or dementia for functional impairment. While several of these causal factors for functional decline in the oldest old are inevitable, some may not be, such as depression. Therefore, developing interventional strategies to prevent depression might be a fruitful approach in order to delay functional impairment in old age.

[Longitudinal Predictors of the Need for Care]. / Einflussfaktoren auf die Pflegebedürftigkeit im Längsschnitt.

Background: Little is known about the longitudinal predictors of the need for care in old age. However, the knowledge of these factors is important for developing strategies for prevention or delay the need for care. Thus, we aimed at investigating the factors affecting the need for care in old age. Methods: In this population-based prospective cohort study (AgeCoDe, with n=3 217 individuals aged 75 years and above at baseline), the need for care was observed over 4.5 years. The need for care was quantified by the care level defined by the German Law (§ 15 SGB XI). Longitudinal predictors (sociodemographic variables, impairment in mobility/hearing/vision, dementia and depression) of the need for care were examined by using Random Effects Logit regressions. Results: Longitudinal regression analysis revealed that the probability of the need for care significantly increased with the occurrence of dementia (OR: 48.2), mobility impairments (aggravated walking, OR: 26.4; disability of walking, OR: 747.9) and age (e. g. 90 years and above vs.<80 years, OR: 32.3). The influence of family status, living conditions, visual impairment and depression on need for care was markedly smaller, and the effect of hearing impairments did not achieve statistical significance. Conclusion: In order to prevent or delay the need for care in old age, treatments should aim at preserving mobility and cognition. Due to demographic ageing, developing such programs is of major importance for health policy.

Predictors of Frailty in Old Age - Results of a Longitudinal Study.

OBJECTIVES: To investigate time-dependent predictors of frailty in old age longitudinally. DESIGN: Population-based prospective cohort study. SETTING: Elderly individuals were recruited via GP offices at six study centers in Germany. The course of frailty was observed over 1.5 years (follow up wave 4 and follow up wave 5). PARTICIPANTS: 1,602 individuals aged 80 years and older (mean age 85.4 years SD 3.2, with mean CSHA CFS 3.5 SD 1.6) at follow up wave 4. MEASUREMENTS: Frailty was assessed by using the Canadian Study of Health and Aging Clinical Frailty Scale (CSHA CFS), ranging from 1 (very fit) to 7 (severely frail). RESULTS: Fixed effects regressions revealed that frailty increased significantly with increasing age (ß=.2) as well as the occurrence of depression (ß=.5) and dementia (ß=.8) in the total sample. Changes in marital status and comorbidity did not affect frailty. While the effects of depression and dementia were significant in women, these effects did not achieve statistical significance in men. CONCLUSION: Our findings highlight the role of aging as well as the occurrence of dementia and depression for frailty. Specifically, in order to delay frailty in old age, developing interventional strategies to prevent depression might be a fruitful approach.

Mortality in incident dementia - results from the German Study on Aging, Cognition, and Dementia in Primary Care Patients.

OBJECTIVE: Dementia is known to increase mortality, but the relative loss of life years and contributing factors are not well established. Thus, we aimed to investigate mortality in incident dementia from disease onset. METHOD: Data were derived from the prospective longitudinal German AgeCoDe study. We used proportional hazards models to assess the impact of sociodemographic and health characteristics on mortality after dementia onset, Kaplan-Meier method for median survival times. RESULTS: Of 3214 subjects at risk, 523 (16.3%) developed incident dementia during a 9-year follow-up period. Median survival time after onset was 3.2 years (95% CI = 2.8-3.7) at a mean age of 85.0 (SD = 4.0) years (≥2.6 life years lost compared with the general German population). Survival was shorter in older age, males other dementias than Alzheimer's, and in the absence of subjective memory complaints (SMC). CONCLUSION: Our findings emphasize that dementia substantially shortens life expectancy. Future studies should further investigate the potential impact of SMC on mortality in dementia.

[FIMA--questionnaire for health-related resource use in an elderly population: development and pilot study]. / FIMA--Fragebogen zur Erhebung von Gesundheitsleistungen im Alter: Entwicklung und Pilotstudie.

AIM: Due to demographic trends towards an ageing population resource use of health care will increase. By collecting health-related costs via questionnaires, the impact of socio-economic variables and other medical factors can be examined. In addition, only patient reported resource use accounts for out-of-pocket payments. Thus, it is necessary to develop an appropriate tool to collect the health-related resource use in an elderly population. METHODS: The development of the FIMA (questionnaire for the use of medical and non-medical services in old age) was carried out in 6 steps. These included the determination of necessary questionnaire contents based on a literature review and the wording and layout were defined. Finally the questionnaire was tested in a pilot study and was modified. RESULTS: All direct medical and non-medical resource use excluding transportation and time costs were recorded. Productivity losses were not included. The recall time frames differed according to resource categories (7 days, 3 months, 12 months). For the pilot study, 63 questionnaires were analysed. The response rate was 69%. The questionnaire took an average of 21 min to complete. Three quarters of respondents completed the questionnaire without help and 90% rated the difficulty as easy or even very simple. There was good agreement between self-reported health-related quality of life and the resource use of nursing and domestic help (phi coefficient values between 0.52 and 0.58). CONCLUSION: The FIMA is a generic questionnaire which collects the health-related resource use within the older population groups.

[Calculation of standardised unit costs from a societal perspective for health economic evaluation]. / Ermittlung standardisierter Bewertungssätze aus gesellschaftlicher Perspektive für die gesundheitsökonomische Evaluation.

PURPOSE: Due to demographic aging, economic evaluation of health care technologies for the elderly becomes more important. A standardised questionnaire to measure the health-related resource utilisation has been designed. The monetary valuation of the resource use documented by the questionnaire is a central step towards the determination of the corresponding costs. The aim of this paper is to provide unit costs for the resources in the questionnaire from a societal perspective. METHODS: The unit costs are calculated pragmatically based on regularly published sources. Thus, an easy update is possible. RESULTS: This paper presents the calculated unit costs for outpatient medical care, inpatient care, informal and formal nursing care and pharmaceuticals from a societal perspective. CONCLUSION: The calculated unit costs can serve as a reference case in health economic evaluations and hence help to increase their comparability.

Apolipoprotein E epsilon 4 genotype and a physically active lifestyle in late life: analysis of gene-environment interaction for the risk of dementia and Alzheimer's disease dementia.

BACKGROUND: As physical activity may modify the effect of the apolipoprotein E (APOE) ε4 allele on the risk of dementia and Alzheimer's disease (AD) dementia, we tested for such a gene-environment interaction in a sample of general practice patients aged ⩾75 years. METHOD: Data were derived from follow-up waves I-IV of the longitudinal German study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe). The Kaplan-Meier survival method was used to estimate dementia- and AD-free survival times. Multivariable Cox regression was used to assess individual associations of APOE ε4 and physical activity with risk for dementia and AD, controlling for covariates. We tested for gene-environment interaction by calculating three indices of additive interaction. RESULTS: Among the randomly selected sample of 6619 patients, 3327 (50.3%) individuals participated in the study at baseline and 2810 (42.5%) at follow-up I. Of the 2492 patients without dementia included at follow-up I, 278 developed dementia (184 AD) over the subsequent follow-up interval of 4.5 years. The presence of the APOE ε4 allele significantly increased and higher physical activity significantly decreased risk for dementia and AD. The co-presence of APOE ε4 with low physical activity was associated with higher risk for dementia and AD and shorter dementia- and AD-free survival time than the presence of APOE ε4 or low physical activity alone. Indices of interaction indicated no significant interaction between low physical activity and the APOE ε4 allele for general dementia risk, but a possible additive interaction for AD risk. CONCLUSIONS: Physical activity even in late life may be effective in reducing conversion to dementia and AD or in delaying the onset of clinical manifestations. APOE ε4 carriers may particularly benefit from increasing physical activity with regard to their risk for AD.

A hierarchy of predictors for dementia-free survival in old-age: results of the AgeCoDe study.

OBJECTIVE: Progression from cognitive impairment (CI) to dementia is predicted by several factors, but their relative importance and interaction are unclear. METHOD: We investigated numerous such factors in the AgeCoDe study, a longitudinal study of general practice patients aged 75+. We used recursive partitioning analysis (RPA) to identify hierarchical patterns of baseline covariates that predicted dementia-free survival. RESULTS: Among 784 non-demented patients with CI, 157 (20.0%) developed dementia over a follow-up interval of 4.5 years. RPA showed that more severe cognitive compromise, revealed by a Mini-Mental State Examination (MMSE) score < 27.47, was the strongest predictor of imminent dementia. Dementia-free survival time was shortest (mean 2.4 years) in such low-scoring patients who also had impaired instrumental activities of daily living (iADL) and subjective memory impairment with related worry (SMI-w). Patients with identical characteristics but without SMI-w had an estimated mean dementia-free survival time of 3.8 years, which was still shorter than in patients who had subthreshold MMSE scores but intact iADL (4.2-5.2 years). CONCLUSION: Hierarchical patterns of readily available covariates can predict dementia-free survival in older general practice patients with CI. Although less widely appreciated than other variables, iADL impairment appears to be an especially noteworthy predictor of progression to dementia.

[Potentially inappropriate medication in elderly primary care patients : A retrospective, longitudinal analysis]. / Potenziell inadäquate Medikamente bei älteren hausärztlich versorgten Patientinnen und Patienten : Eine retrospektive Längsschnittanalyse.

BACKGROUND: Elderly people are often burdened by several diseases. This accounts for a higher medication intake and increases the risk of adverse drug events. To minimize this risk, several lists (Beers, PRISCUS) have been published of drugs that elderly patients should not take. We present a longitudinal analysis of the use of potentially inappropriate medication (PIM) over a period 4.5 years in a cohort of patients aged 75 years or more. METHODS: Data were collected from the prospective, multicenter, observational study "German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe)," initially enrolling 3,327 patients. We investigated the prevalence of PIM by checking medications during visits to patients' homes. Furthermore, we analyzed the use of individual PIM agents over time. RESULTS: At baseline, we found a PIM prevalence of 29 % according to the PRISCUS list, which decreased to 25.0 % 4.5 years later (χ(2): 7.87, p = 0.004). The Beers list yielded a prevalence of 21 % at baseline, decreasing after 4.5 years to 17.1 % (χ(2): 10.77, p = 0.000). A time-dependent multilevel model confirmed these results. Older age, depression, and the use of numerous prescribed agents are independent risk factors for using a PRISCUS-PIM. CONCLUSION: Our results seem to support a trend toward a more rational drug therapy because fewer patients were prescribed PIM. Thus, for the individual patient, the risk of adverse effects and side effects is reduced as are the costs of these effects.

[Costs of diseases with long-term survival]. / Kostenmessung bei Krankheiten mit Langzeitüberleben.

In the past decades medical progress in the treatment of fatal diseases has led to substantial improvement of survival. This long-term survival has financial consequences for health care and society. In this article methodological challenges of measuring the costs of long-term survival are presented. In this regard the costs of long-term treatment, indirect costs, unrelated future health care costs and discounting of costs are highlighted and illustrated by examples. A methodological challenge related to the economic evaluation of therapies leading to long-term survival is the consideration of unrelated future health care costs occurring in life years gained. In the literature the issue of unrelated future health care costs is discussed comprehensively on a methodological-theoretical basis. In economic evaluations published in the literature, these costs have rarely been considered so far, which may cause biased results. Concerning the comparability of study results, a standardization of the methods of measuring costs is desirable.