Social isolation in the oldest-old: determinants and the differential role of family and friends.

PURPOSE: To examine the association of sociodemographic and health-related determinants with social isolation in relation to family and friends in the oldest-old. METHODS: Database was the multi-center prospective AgeCoDe/AgeQualiDe cohort study assessed at follow-up wave 5 (N = 1148; mean age 86.6 years (SD 3.0); 67% female). Social isolation was assessed using the short form of the Lubben Social Network Scale (LSNS-6). The LSNS-6 contains two sets of items establishing psychometrically separable subscales for isolation from family and friends (ranges 0-15 points), with lower scores indicating higher isolation. Cross-sectional linear (OLS) regression analyses were used to examine multivariate associations of sociodemographic and health-related determinants with social isolation from family and friends. RESULTS: Overall, n = 395 participants (34.6%) were considered socially isolated. On average, isolation was higher from friends (mean 6.0, SD 3.8) than from family (mean 8.0, SD 3.5). Regression results revealed that in relation to family, males were more socially isolated than females (ß = - 0.68, 95% CI - 1.08, - 0.28). Concerning friends, increased age led to more isolation (ß = - 0.12, 95% CI - 0.19, - 0.05) and functional activities of daily living to less isolation (ß = 0.36, 95% CI 0.09, 0.64). Independent of the social context, depression severity was associated with more social isolation, whereas cognitive functioning was associated with less social isolation. CONCLUSIONS: Different determinants unequally affect social isolation in relation to family and friends. The context of the social network should be incorporated more strongly regarding the detection and prevention of social isolation to sustain mental and physical health.

Disentangling the relationship of subjective cognitive decline and depressive symptoms in the development of cognitive decline and dementia.

INTRODUCTION: Subjective cognitive decline (SCD) and depressive symptoms (DS) frequently co-occur prior to dementia. However, the temporal sequence of their emergence and their combined prognostic value for cognitive decline and dementia is unclear. METHODS: Temporal relationships of SCD, DS and memory decline were examined by latent difference score modeling in a high-aged, population-based cohort (N = 3217) and validated using Cox-regression of dementia-conversion. In 334 cognitively unimpaired SCD-patients from memory-clinics, we examined the association of DS with cognitive decline and with cerebrospinal fluid (CSF) Alzheimer's disease (AD) biomarkers. RESULTS: In the population-based cohort, SCD preceded DS. High DS were associated with increased risk of dementia conversion in individuals with SCD. In SCD-patients from memory-clinics, high DS were associated with greater cognitive decline. CSF Aß42 predicted increasing DS. DISCUSSION: SCD typically precedes DS in the evolution to dementia. SCD-patients from memory-clinics with DS may constitute a high-risk group for cognitive decline. HIGHLIGHTS: Subjective cognitive decline (SCD) precedes depressive symptoms (DS) as memory declines. Emerging or persistent DS after SCD reports predict dementia. In SCD patients, more amyloid pathology relates to increasing DS. SCD patients with DS are at high risk for symptomatic progression.

Higher FORTA (Fit fOR The Aged) scores are associated with poor functional outcomes, dementia, and mortality in older people.

PURPOSE: Higher Fit fOR The Aged (FORTA) scores have been shown to be negatively associated with adverse clinical outcomes in older hospitalized patients. This has not been evaluated in other health care settings. The aim of this study was to examine the association of the FORTA score with relevant outcomes in the prospective AgeCoDe-AgeQualiDe cohort of community-dwelling older people. In particular, the longitudinal relation between the FORTA score and mortality and the incidence of dementia was evaluated. METHODS: Univariate and multivariate correlations between the FORTA score and activities of daily living (ADL) or instrumental activities of daily living (IADL) as well as comparisons between high vs. low FORTA scores were conducted. RESULTS: The FORTA score was significantly correlated with ADL/IADL at baseline and at all follow-up visits (p < 0.0001). ADL/IADL results of participants with a low FORTA score were significantly better than in those with high FORTA scores (p < 0.0001). The FORTA score was also significantly (p < 0.0001) correlated with ADL/IADL in the multivariate analysis. Moreover, the mean FORTA scores of participants with dementia were significantly higher (p < 0.0001) than in those without dementia at follow-up visits 6 through 9. The mean FORTA scores of participants who died were significantly higher than those of survivors at follow-up visits 7 (p < 0.05), 8 (p < 0.001), and 9 (p < 0.001). CONCLUSION: In this study, an association between higher FORTA scores and ADL as well as IADL was demonstrated in community-dwelling older adults. Besides, higher FORTA scores appear to be linked to a higher incidence of dementia and even mortality.

Social Support and Functional Decline in the Oldest Old.

OBJECTIVE: Longitudinal studies investigating the link between social support and functional decline are limited among the oldest old. Thus, the aim of this study was to examine whether changes in social support are associated with functional decline among the oldest old longitudinally using panel regression models. METHODS: Longitudinal data from 3 waves (waves 7, 8, and 9) of a multicenter prospective cohort study covering primary care patients aged ≥85 years were used. In the analytical sample, n equaled 624 individuals. The validated Lawton and Brody Instrumental Activities of Daily Living (IADL) scale and the well-established Barthel Index (ADL) were used to quantify functional status. The psychometrically sound Lubben Social Network Scale was used to measure social support. Several potential confounders such as age, marital status, cognitive decline, or depressive symptoms were included in the fixed effects (FE) regression models. RESULTS: Linear FE regressions showed that a decrease in social support is associated with functional decline (IADL: ß = 0.03, p < 0.05; ADL: ß = 0.27, p < 0.05) in men but not in women. With IADL as outcome measure, the interaction term (sex × social support) achieved statistical significance (p < 0.01). With regard to covariates, functional decline (IADL and ADL) was consistently associated with increasing age, an increase in the number of chronic conditions (except for women [ADL]), and cognitive decline (except for men [ADL]). Furthermore, functional decline (ADL) was associated with an increase in depressive symptoms. DISCUSSION: Our findings highlight the meaning of social support for functional status among the oldest old. Finding ways to sustain social support in highest age may be a promising approach in order to postpone functional decline.

Factors Leading to Institutionalization among the Oldest Old: Longitudinal Findings from the AgeCoDe-AgeQualiDe Study.

INTRODUCTION: Due to the strong association between old age and the need for long-term care, the number of individuals in need for care is projected to increase noticeably. The aim of this study was to examine the determinants of institutionalization among the oldest old longitudinally. METHODS: Longitudinal data (follow-up [FU] wave 7-9) were gathered from a multicenter prospective cohort study ("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). At FU wave 7, in 2014, complete measures were available for 763 individuals. The average age was 88.9 (standard deviation 2.9) years (range 85-100), and 68% were female. Sociodemographic and health-related independent variables (e.g., depressive symptoms or functioning) were included in the regression model. Institutionalization (admission to assisted living home or nursing home) was used as an outcome measure. Logistic random-effects models were used. RESULTS: Regressions revealed that among oldest old, the odds of being institutionalized were lower for men (odds ratio [OR] = 0.03; 95% confidence interval [CI] 0.00-0.16). Institutionalization was associated with an increased age (OR = 1.27; 95% CI 1.04-1.55). Additionally, widowed individuals (ref. non-widowed) had higher odds of being institutionalized (OR = 8.95; 95% CI 1.61-49.81). Institutionalization was also associated with functional decline (OR = 0.16; 95% CI 0.11-0.23), whereas it was not significantly associated with cognitive decline, depressive symptoms, and social support. CONCLUSION: Our findings stress the importance of gender, age, widowhood, and functional decline for institutionalization among the oldest old. Preventing or at least postponing functional decline might help to delay institutionalization as far as possible.

Predictors of change in depressive symptoms in older and multimorbid patients: a longitudinal analysis of the multicare cohort.

BACKGROUND: Depression in older adults is becoming an increasing concern. As depressive symptoms change over time, it is important to understand the determinants of change in depressive symptoms. The aim of our study is to use a longitudinal study design to explore the predictors of change, remission and incident depression in older patients with multimorbidity. METHODS: Data from the MultiCare cohort study were used. The cohort studied 3,189 multimorbid general practice patients aged 65-85. Data were collected during personal interviews. Depressive symptoms were assessed using the Geriatric Depression Scale (GDS-15). Predictors of change in depressive symptoms were determined using multivariate linear regression, while multivariate logistic regression was used to analyze predictors of remission and incident depression. Models included depressive symptoms at baseline and follow-up, socio-demographics and data on health status and social support. RESULTS: Overall, 2,746 participants with complete follow-up data were analyzed. Mean age was 74.2 years, 59.2% were female, and 11.3% were classified as depressed at baseline. Burden of multimorbidity and social support were statistically significant predictors in all regression analyses. Further predictors of change in depressive symptoms were: income, pain, nursing grade, self-rated health and self-efficacy. LIMITATIONS: The sample size for prediction of remission limited statistical certainty. Assessment of depressive symptoms using GDS-15 differs from routine clinical diagnoses of depression. CONCLUSIONS: Predictors of change in depressive symptoms in older multimorbid patients are similar to those predicting remission and incident depression, and do not seem to differ significantly from other older patient populations with depressive symptoms.

Correlates of institutionalization among the oldest old-Evidence from the multicenter AgeCoDe-AgeQualiDe study.

OBJECTIVES: There is a lack of studies identifying the correlates of institutionalization specifically among the oldest old. Therefore, our aim was to fill this gap in knowledge. METHODS: Cross-sectional data (Follow up wave 9; n = 633 observations in the analytical sample) were used from the multicenter prospective cohort study "Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" Correlates of institutionalization among the oldest old-Evidence from a multicenter cohort study. The sample consists of primary care patients aged 86 years and over (mean 90.5 years, SD: 2.9 years). Sociodemographic and health-related independent variables were included in our regression model. Institutionalization was defined as living in a nursing home or an old-age home (not including assisted living facilities). RESULTS: Out of the 633 participants, 502 individuals (79.3%) did not live in an institutionalized setting, whereas 73 individuals (20.7%) lived in an institutionalized setting. Multiple logistic regressions showed that the likelihood of institutionalization increased with being divorced/widowed/single (compared to being married; OR: 5.35 [95% CI: 1.75-16.36]), the presence of social isolation (OR: 2.07 [1.20-3.59]), more depressive symptoms (OR: 1.11 [1.01-1.23]), increased cognitive impairment (OR: 1.67 [1.31-2.15]) and higher levels of frailty (OR: 1.48 [1.07-2.06]). CONCLUSION: The study findings identified various sociodemographic and health-related factors associated with institutionalization among the oldest old. Longitudinal studies are required to gain further insights into these associations.

Effects of APOE e4-allele and mental work demands on cognitive decline in old age: Results from the German Study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe).

OBJECTIVES: Previous studies have observed protective effects of high mental demands at work on cognitive functioning and dementia risk. However, it is unclear what types of demands drive this effect and whether this effect is subject to a person's genetic risk. We investigated to what extent eight different types of mental demands at work together with the APOE e4 allele, a major risk gene for late-onset Alzheimer's disease, affect cognitive functioning in late life. METHODS/DESIGN: The population-based German Study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe, n = 2 154) followed cognitively healthy individuals aged 75 years and older in seven assessment waves. Cognitive functioning was assessed via the mini-mental status examination. RESULTS: Mixed-effects modeling (adjusted for education, gender, marital status, stroke, depression, and diabetes) indicated that participants who had an occupational history of working in jobs with high compared to low demands in "Language & Knowledge", "Pattern detection", "Information processing", and "Service" had a slower cognitive decline. APOE e4-allele carriers had an accelerated cognitive decline, but this decline was significantly smaller if they had a medium compared to a low level of demands in contrast to non-carriers. CONCLUSIONS: Our longitudinal observations suggest that cognitive decline could be slowed by an intellectually enriched lifestyle even in risk gene carriers. Fostering intellectual engagement throughout the life-course could be a key prevention initiative to promote better cognitive health in old age.

Frailty and Autonomy among the Oldest Old: Evidence from the Multicenter Prospective AgeCoDe-AgeQualiDe Study.

INTRODUCTION: There is a lack of studies examining the link between perceived autonomy and frailty among the oldest old. Therefore, our objective was to fill this gap. METHODS: Data were used from the multicenter prospective cohort study "Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe; follow-up [FU] wave 9; n = 510 observations in the analytical sample). The average age was 90.3 years (SD: 2.7 years). The Canadian Study of Health and Aging (CSHA) Clinical Frailty Scale (CFS) was used to assess frailty. Socioeconomic and health-related covariates were included in our regression model. The autonomy scale developed by Schwarzer was used to assess perceived autonomy in old age. RESULTS: Adjusting for various confounders, multiple linear regressions showed that lower perceived autonomy was associated with increased levels of frailty (total sample: ß = -0.13, p < 0.001; women: ß = -0.14, p < 0.001; and men: ß = -0.12, p < 0.001). Furthermore, lower perceived autonomy was associated with more depressive symptoms, higher cognitive impairment, and being institutionalized (except for men) in the total sample and in both sexes, but it was not significantly associated with age, sex, marital status, educational level, and social support. CONCLUSION: Findings indicate that frailty is associated with lower autonomy among the oldest old. More generally, while health-related factors were consistently associated with autonomy, sociodemographic factors (except for being institutionalized) were not associated with autonomy among the oldest old. We should be aware of the strong association between autonomy and physical as well as mental health in very old age.

Driving status and health-related quality of life among the oldest old: a population-based examination using data from the AgeCoDe-AgeQualiDe prospective cohort study.

BACKGROUND: It is almost unknown whether the driving status is associated with HRQOL among individuals in highest age. AIMS: Based on a multicenter prospective cohort study, the objective of this study was to examine whether the driving status is associated with health-related quality of life (HRQOL) among the oldest old in Germany. METHODS: Cross-sectional data from follow-up wave 9 (n = 544) were derived from the "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). Average age was 90.3 years (± 2.7; 86 to 101 years). The current driver status (no; yes) was used in our analysis. The EuroQoL EQ-5D questionnaire was used to assess HRQOL in this study. RESULTS: Regression analysis showed that being a current driver was associated with the absence of problems in 'self-care' [OR 0.41 (95%-CI 0.17 to 0.98)], and 'usual activities' [OR 0.48 (0.26 to 0.90)], whereas it was not significantly associated with problems in 'pain/discomfort' [OR  0.82 (0.47 to 1.45)] and 'anxiety/depression' [OR  0.71 (0.36 to 1.39)]. Being a current driver was marginally significantly associated with the absence of problems in 'mobility' [OR 0.60 (0.34 to 1.06)]. While being a current driver was not associated with the EQ-VAS in the main model, it was positively associated with the driving status (ß = 5.00, p < .05) when functional impairment was removed from the main model. DISCUSSION: Our findings provide first evidence for an association between driving status and HRQOL among the oldest old. CONCLUSIONS: Future longitudinal studies are required to evaluate a possible causal relationship between driving status and HRQOL in very old individuals.

Mild cognitive impairment and quality of life in the oldest old: a closer look.

PURPOSE: Mild cognitive impairment (MCI) is a widespread phenomenon, especially affecting older individuals. We will analyze in how far MCI affects different facets of quality of life (QOL). METHODS: We used a sample of 903 participants (110 with MCI) from the fifth follow-up of the German Study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe), a prospective longitudinal study, to analyze the effects of MCI on different facets of the WHOQOL-OLD. We controlled for age, gender, marital status, education, living situation, daily living skills, and the ability to walk, see, and hear. RESULTS: Univariate analyses showed that individuals with MCI exhibited lower QOL with regard to the facets autonomy; past, present, and future activities; social participation; and intimacy, but less fears related to death and dying. No significant difference was shown with regard to the facet sensory abilities. In multivariate analyses controlling for age, gender, marital status, education, living situation, daily living skills, and the ability to walk, see and hear, MCI-status was significantly associated with QOL in the facet autonomy. CONCLUSION: Effects of MCI go beyond cognition and significantly impact the lives of those affected. Further research and practice will benefit from utilizing specific facets of QOL rather than a total score.

EQ-5D-3L health status and health state utilities of the oldest-old (85 +) in Germany: results from the AgeCoDe-AgeQualiDe study.

PURPOSE: To describe health status and health state utilities measured by the EQ-5D-3L in a population-based sample of individuals aged 85 + in Germany, and to analyze associations with basic socio-demographic variables. METHODS: Cross-sectional data from follow-up wave 7 (n = 761) of the German AgeCoDe Study were used. The EQ-5D-3L questionnaire was used to record problems in five health dimensions, its visual analogue scale (EQ VAS) was used to record self-rated health status, and the German EQ-5D-3L index was used to derive health state utilities. RESULTS: Mean age of respondents was 88.9 years (SD 2.9; range 85 to 100), 67.4% were female. 81.9% reported problems in at least one of the EQ-5D dimensions, with 15.3% reporting extreme problems. Most frequent were problems with pain/discomfort (64.8%), followed by mobility (62.5%), usual activities (42.6%), self-care (28.2%), and anxiety/depression (20.5%). Mean EQ VAS score was 62.4 (SD 18.8), and mean EQ-5D index was 0.77 (SD 0.24). Multiple regression analysis showed associations of problem frequency in various EQ-5D dimensions with age, gender, living situation, marital status, and education. The EQ VAS score was negatively associated with age (ß = - 0.56; p < 0.05) and female gender (ß = - 3.49; p < 0.05). The EQ-5D index was negatively associated with not living in the community (ß = - 0.10; p < 0.001) and being single (ß = - 0.09; p < 0.05). CONCLUSIONS: The results show a substantially impaired health status of the oldest-old population. The data can be used for comparing health status of population groups as well as for health economic models.

Determinants of incident dementia in different old age groups: results of the prospective AgeCoDe/AgeQualiDe study.

OBJECTIVES: To examine the impact of determinants of incident dementia in three different old age groups (75-79, 80-84, 85+years) in Germany. DESIGN: Multicenter prospective AgeCoDe/AgeQualiDe cohort study with baseline and nine follow-up assessments at 1.5-year intervals. SETTING: Primary care medical record registry sample. PARTICIPANTS: General practitioners' (GPs) patients aged 75+years at baseline. MEASUREMENTS: Conduction of standardized interviews including neuropsychological assessment and collection of GP information at each assessment wave. We used age-stratified competing risk regression models (accounting for the competing event of mortality) to assess determinants of incident dementia and age-stratified ordinary least square regressions to quantify the impact of identified determinants on the age at dementia onset. RESULTS: Among 3027 dementia-free GP patients, n = 704 (23.3%) developed dementia during the 13-year study period. Worse cognitive performance and subjective memory decline with related worries at baseline, and the APOE ε4 allele were associated independently with increased dementia risk in all three old age groups. Worse cognitive performance at baseline was also associated with younger age at dementia onset in all three age groups. Other well-known determinants were associated with dementia risk and age at dementia onset only in some or in none of the three old age groups. CONCLUSIONS: This study provides further evidence for the age-specific importance of determinants of incident dementia in old age. Such specifics have to be considered more strongly particularly with regard to potential approaches of early detection and prevention of dementia.

Prediction of dementia of Alzheimer type by different types of subjective cognitive decline.

INTRODUCTION: Subjective cognitive decline (SCD) is a risk condition for dementia, including dementia of Alzheimer type (DAT). METHODS: We report sensitivity, specificity, positive and negative predictive values (PPV, NPV) for conversion to all-cause dementia, and DAT in different SCD types (decline in memory, assocated worries, longitudinal consitency, of the AgeCoDe study (n = 2.402, 12 years follow-up). RESULTS: 82.7% of those converting to any dementia and 84.4% of those converting with DAT at follow-up, reported memory decline and fulfilled criteria of SCD at least at one time point before. SCD with worries at two consecutive time points showed a specificity of 92.2% for any dementia and also for DAT as well as a PPV of 44.3% for any dementia and of 36.9% for DAT at follow-up at the expense of low sensitivity. DISCUSSION: Different SCD subtypes were either sensitive or specific for future all-cause dementia and DAT in cognitively unimpaired individuals. Modest PPV of the most specific SCD subtypes were achieved in this low prevalence population.

Association of anxiety symptoms with health care use and costs in people aged 85 and over.

OBJECTIVE: To analyze the association of anxiety symptoms with health care use and costs in people aged 85 and older. METHODS: Baseline data from AgeQualiDe (N = 856), a multicenter prospective cohort study of primary care patients aged 85 and older, were analyzed. Anxiety symptoms (Geriatric Anxiety Inventory-Short Form) and health care use were assessed via questionnaires. Health care use was monetarily valued using German unit costs to obtain sectoral (inpatient, outpatient, nursing care, medical supplies, and medication) and total costs. Health care use and costs were analyzed in regression models as a function of anxiety symptoms, as well as relevant covariates (predisposing, enabling, and other need characteristics based on the Behavioral Model of Health Care Use). RESULTS: On a descriptive level, people with increased anxiety symptoms (12% of the sample) incurred on average € 10 909 (SD: 16 023) in the last 6 months, 31% more than those without increased anxiety (€ 8303, SD: 11 175; P = 0.12). Adjusting for predisposing, enabling, and other need characteristics, anxiety symptoms were not significantly associated with health care use or costs. Specifically, need characteristics (morbidity, cognitive decline, and functional impairment) were associated with total or sectoral costs, depending on the cost category analyzed. CONCLUSION: In a sample of people of the oldest-old age group, the severity of anxiety symptoms was not associated with health care use or costs, when adjusting for relevant covariates. A longitudinal analysis could assess whether a change in anxiety symptom severity is associated with health care use or costs in old age.

Is function in instrumental activities of daily living a useful feature in predicting Alzheimer's disease dementia in subjective cognitive decline?

OBJECTIVE: Subjective cognitive decline (SCD), the earliest symptom in preclinical Alzheimer's disease (AD), is insufficient to identify individuals at risk for AD dementia. Therefore, we aimed to investigate whether function in instrumental activities of daily living (IADL) contributes to identification. METHODS: We analysed data of cognitively unimpaired participants of the prospective German Study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe) and its extension, the Study on Needs, Health Service Use, Costs and Health-related Quality of Life in a Large Sample of Oldest-old Primary Care Patients (AgeQualiDe), collected over 10.5 years. Development of AD dementia was quantified as incidence rates (IRs) per 1000 person-years. Cox regression was used to assess the association of SCD and IADL function in regard to incident AD dementia. RESULTS: Of 1467 included individuals, 792 (54.0%) reported SCD at baseline. Impaired IADL were present in 50 (3.4%) individuals. IR for AD dementia was highest in individuals with SCD and impaired IADL (49.7; 95% CI, 24.8-99.3). Unadjusted and adjusted Cox analyses revealed an increased AD dementia risk for individuals with SCD and impaired IADL (uHR = 6.1; 95% CI, 2.9-13.0; P < 0.001; aHR = 2.5; 95% CI, 1.1-5.7; P < 0.05). CONCLUSIONS: Consistent with the SCD concept, IADL function was largely well preserved in the majority of individuals with SCD. However, if difficulties in IADL were present, risk for AD dementia was increased. Therefore, screening for IADL impairment could serve as an economically viable indicator to assess AD dementia risk above and beyond SCD.

Care challenges in older general hospital patients : Impact of cognitive impairment and other patient-related factors.

BACKGROUND: Older general hospital patients, particularly those with cognitive impairment, frequently experience adverse events and other care complications during their stay. As these findings have so far been based on small and selected patient samples, the aim of the present study was to provide reliable data on a) the prevalence of adverse care issues (summarized under the term care challenges) in older general hospital patients and on b) associated patient-related risk factors (e.g. cognitive impairment). METHODS: A cross-sectional representative study comprising 1469 patients aged ≥65 years from 33 randomly selected general hospitals in southern Germany (GHoSt). Data collection included the use of different data sources, e.g. structured interviews with responsible nursing staff concerning care challenges and procedures for determining the patients' cognitive status. RESULTS: Care challenges were statistically significantly (p < 0.001) more often reported for patients with dementia and/or delirium (87.5%) and mild cognitive impairment (47.9%) compared to cognitively unimpaired patients (24.6%). Adjusted odds ratios suggested cognitive impairment, impaired activities of daily living, receiving long-term care and unplanned admission as significant patient-related risk factors for care challenges. Furthermore, the occurrence of such issues was associated with the application of physical restraints, support from relatives, prescription of psycholeptics and specialist consultations. CONCLUSION: The findings suggest a strong impact of different degrees of cognitive impairment on challenges in care. The results might help to design appropriate training programs for hospital staff and other interventions to prevent or reduce critical situations.

Impact of falls on depressive symptoms among the oldest old: Results from the AgeQualiDe study.

OBJECTIVE: The purpose of this study was to examine the impact of falls on depressive symptoms among the oldest old in Germany longitudinally. METHODS: Data were used from 2 waves of the 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). This study covers primary care patients ≥85 years (at baseline: n = 547, average age of 88.9 ± 3.0 years; ranging from 85 to 100 years). General practitioner-diagnosed falls were used as explanatory variable. The Geriatric Depression Scale was used as outcome measure. RESULTS: Linear fixed effects regressions showed that the occurrence of falls is associated with an increase in depressive symptoms (ß = .60, P = .02), whereas changes in marital status, ageing, social support, functional decline (instrumental activity of daily living), cognitive impairment, and an increase in chronic diseases did not affect depressive symptoms. In sensitivity analysis, an increase in depressive symptoms was associated with functional impairment (basic activities of daily living; Barthel index; ß = -.04, P = .005). CONCLUSIONS: Based on a large, population-based longitudinal study, this study underlined the impact of falls on depressive symptoms and consequently extended previous knowledge about an association between falls and depressive symptoms in the oldest old. Developing strategies to prevent falls might also help to prevent depressive symptoms.

Cross-cultural validation of the German version of the Four-Dimensional Symptom Questionnaire (4DSQ) in multimorbid elderly people.

PURPOSE: Psychosomatic symptoms and mental health problems are highly prevalent in multimorbid elderly people challenging general practitioners to differentiate between normal stress and psychopathological conditions. The 4DSQ is a Dutch questionnaire developed to detect anxiety, depression, somatization, and distress in primary care. This study aims to analyze measurement equivalence between a German version and the original Dutch instrument. METHODS: A Dutch and a German sample of multimorbid elderly people, matched by gender and age, were analyzed. Equivalence of scale structures was assessed by confirmatory factor analysis (CFA). To evaluate measurement equivalence across languages, differential item functioning (DIF) was analyzed using Mantel-Haenszel method and hybrid ordinal logistic regression analysis. Differential test functioning (DTF) was assessed using Rasch analysis. RESULTS: A total of 185 German and 185 Dutch participants completed the questionnaire. The CFA confirmed one-factor models for all scales of both 4DSQ versions. Nine items in three scales were flagged with DIF. The anxiety scale showed to be free of DIF. DTF analysis revealed negligible scale impact of DIF. CONCLUSIONS: The German 4DSQ demonstrated measurement equivalence to the original Dutch instrument. Hence, it can be considered a valid questionnaire for the screening for mental health problems in primary care.

[Dementia friendly care services in general hospitals : Representative results of the general hospital study (GHoSt)]. / Demenzsensible Versorgungsangebote im Allgemeinkrankenhaus : Repräsentative Ergebnisse aus der General Hospital Study (GHoSt).

BACKGROUND: Mostly model projects report on special care services and procedures for general hospital patients with cognitive impairment. The objective of this study was to determine the frequency of special care services and procedures in general hospitals on the basis of a representative cross-sectional study. METHODS: From a list of all general hospitals in southern Germany we randomly selected a specified number of hospitals und somatic wards. The hospitals were visited and all older patients on the selected wards on that day were included in the study. Information about care services and their utilization was collected with standardized instruments. RESULTS: A total of 33 general hospitals and 172 wards participated in the study. The patient sample included 1469 persons over 65 (mean age 78.6 years) and 40% of the patients showed cognitive impairments. The staff reported that the most frequent measures for patients with cognitive impairments concerned patients with wandering behavior (63.1%), efforts to involve the patients' relatives to help with their daily care (60.1%), conducting nonintrusive interviews to identify cognitive impairments (59.9%), allocation to other rooms (58%) and visual aids for place orientation of patients (50.6%). In accordance with earlier studies our results show that other dementia friendly services implemented in pilot projects were rare. The existing special services for patients with cognitive impairment were rarely used by the patients or their relatives. DISCUSSION: The results demonstrate the urgent need to improve special care services and routines for identification of elderly patients with cognitive impairment and risk of delirium in general hospitals.