Characterization of patients admitted to specialized geriatric acute care hospital units with the German version of the Standardized Evaluation and Intervention for Seniors at Risk (SEISAR) screening-instrument: a cross-sectional study.

BACKGROUND: The Standardized Evaluation and Intervention for Seniors at Risk (SEISAR) screening tool records major geriatric problems, originally applied in the emergency department. Particularly, the distinction of compensated and uncompensated problems is an interesting and new approach. Therefore, we translated the SEISAR in German language and used it to characterize patients in specialized geriatric hospital wards in Germany and to gather initial experience regarding its usability and practicability. METHODS: The tool was translated by three independent specialists in geriatric medicine and backtranslated for quality-assurance by a non-medical English native speaker. In a second step, 8 acute care geriatric hospital departments used the translated version to characterize all consecutive patients admitted over a period of one month between December 2019 and May 2020 at time of admission. RESULTS: Most of the 756 patients (78%) lived in an own apartment or house prior to hospital admission. Participants had on average 4 compensated and 6 uncompensated problems, a Barthel-Index of 40 pts. on admission with a median increase of 15 points during hospital stay, and a median length of stay of 16 days in the geriatric hospital department. CONCLUSION: SEISAR is an interesting standardized brief comprehensive geriatric assessment tool for the identification of compensated and uncompensated health problems in older persons. The data of this study highlights the number, variability, and complexity of geriatric problems in patients treated in specialized acute care geriatric hospital wards in Germany. TRIAL REGISTRATION: German Clinical trial register (DRKS-ID: DRKS00031354 on 27.02.2023).

Impact of clinical osteoarthritis of the hip, knee and hand on self-rated health in six European countries: the European Project on OSteoArthritis.

PURPOSE: Osteoarthritis (OA) has been shown to be associated with decreased physical function, which may impact upon a person's self-rated health (SRH). Only a few studies have examined the association between OA and SRH in the general population, but to date none have used a clinical definition of OA. The objectives are: (1) To examine the cross-sectional association between clinical OA and fair-to-poor SRH in the general population; (2) To examine whether this association differs between countries; (3) To examine whether physical function is a mediator in the association between clinical OA and SRH. METHODS: Baseline data of the European Project on OSteoArthritis (EPOSA) were used, which includes pre-harmonized data from six European cohort studies (n = 2709). Clinical OA was defined according to the American College of Rheumatology criteria. SRH was assessed using one question: How is your health in general? Physical function was assessed using the Western Ontario and McMaster Universities OA Index and Australian/Canadian OA Hand Index. RESULTS: The prevalence of fair-to-poor SRH ranged from 19.8 % in the United Kingdom to 63.5 % in Italy. Although country differences in the strength of the associations were observed, clinical OA of the hip, knee and hand were significantly associated with fair-to-poor SRH in five out of six European countries. In most countries and at most sites, the association between clinical OA and fair-to-poor SRH was partly or fully mediated by physical function. CONCLUSIONS: Clinical OA at different sites was related to fair-to-poor SRH in the general population. Most associations were (partly) mediated by physical functioning, indicating that deteriorating physical function in patients with OA should be a point of attention in patient care.

[Pain therapy in German long-term care facilities in a European comparison. Results of the SHELTER study]. / Schmerztherapie in deutschen Pflegeeinrichtungen im europäischen Vergleich. Ergebnisse der SHELTER-Studie.

BACKGROUND: A considerable number of nursing home residents suffering from pain are insufficiently treated. International comparisons of pain management in German (GER) and other European (EU) nursing homes are still lacking. OBJECTIVE: This study compared the treatment of pain in GER and EU nursing homes in order to improve allocation of therapeutic resources. MATERIAL AND METHODS: A cross-sectional study was carried out with 4156 residents assessed using the interRAI instrument for long-term care facilities, including pharmacological and non-pharmacological pain management modalities. Only those residents reporting pain were included in the analyses (n = 1900 from EU and 245 from GER). Descriptive analyses and analyses of correlations between different parameters and pain were performed. RESULTS: More than three quarters of the residents with at least moderate pain received pharmacological treatment (GER: 77.4 % and EU: 79.3 %). Combination therapy (pharmacological and non-pharmacological) was more frequent in Germany (approximately 13 %). Even in cases of moderate to severe pain one third of GER compared to one quarter of the EU residents received either no analgesic treatment or only on a when needed basis (PRN). Differences were also seen in drugs used (GER metamizole). The amount of PRN was higher in Germany (approximately 13 %, alone or in combination). Only 5 % received the recommended level of non-pharmacological treatment. Pain severity and decubitus were identified as important triggers for pharmacological treatment. Non-pharmacological treatment was used less often than analgesics (EU: 39.2 %, GER: 46.8 %). There were no differences regarding administration frequency and intensity of non-pharmacological treatments in residents with or without pain; however, non-pharmacological treatment was used less often in residents with successful pharmacological treatment. CONCLUSION: The data demonstrate significant deficits in the recognition and treatment of pain in residents living in German or other European nursing home facilities. Further scope for improvement is seen in better recognition of relevant pain, in the adequate use of PRN and long-term medication and especially in the use of activating non-pharmacological treatment.

Prospective evaluation of renal function, serum vitamin D level, and risk of fall and fracture in community-dwelling elderly subjects.

SUMMARY: This prospective study in elderly showed that kidney function plays a minor role in explaining the high prevalence of vitamin D deficiency seen in noninstitutionalized elderly subjects. However, 25-hydroxyvitamin D levels were clearly inversely associated with risk for first fall, which was especially seen in subjects with calcium levels above median. INTRODUCTION: Few prospective studies in elderly exist that have investigated the association of renal dysfunction and vitamin D status on risk of falls. The aim of this study is to evaluate the association of renal function with 25-hydroxyvitamin D (25-OH-D) levels and, secondly, to assess the role of both factors on the risk of falls and subsequent bone fractures. METHODS: This is a prospective population-based cohort study among noninstitutionalized elderly subjects during a 1-year follow-up. 25-OH-D levels and renal function were estimated, the latter by cystatin C-based equations. Information on falls was assessed prospectively. RESULTS: Overall, 1,385 subjects aged 65 and older were included in the study (mean age 75.6 years), of whom 9.2 % had a 25-OH-D serum level above 75 nmol/L (US units 30 ng/mL); 41.4 %, between 50 and 75 nmol/L (US units 20 to 29 ng/mL, insufficiency); and 49.4 %, <50 nmol/L (US units <20 ng/mL, deficiency). We found no association of chronic kidney disease with risk of first fall. In contrast, 25-OH-D serum categories were clearly associated with risk of first fall and we found evidence of effect modification with calcium levels. In the group with a calcium level above the median (≥ 9.6 mg/dL), subjects with 25-OH-D serum level between 50 and 75 nmol/L and with concentrations <50 nmol/L had a hazard rate ratio (HRR) of 1.75 (1.03-2.87) and 1.93 (1.10-3.37) for risk of first fall. 25-OH-D serum levels were also associated with several markers of inflammation and hemodynamic stress. CONCLUSIONS: We demonstrated an association of 25-OH-D serum levels and risk of first fall, which was especially evident in subjects with serum calcium in upper normal, independent of renal function.

Physical activity for the prevention of cognitive decline: current evidence from observational and controlled studies.

A sedentary life style has been associated with different types of dementia in several cross sectional, longitudinal, and case-controlled studies. However, randomized controlled trials that support this relationship are rare, have rather few participants, and mainly focus on physical (usually aerobic) exercise. The benefit of an increased physical activity (PA) has been mainly demonstrated for the prevention of Alzheimer's disease and vascular dementia, less so for other dementia types such as Lewy body dementia or frontotemporal dementia. The clinical evidence builds on a significant amount of animal research pointing to potential mechanisms as to how PA relates to cognitive function. While most studies have investigated singular interventions, others have studied the combination of both mental and physical activity to improve cognition or delay decline. However, questions remain such as what type and how much PA is beneficial? This review gives an overview of the current evidence on the clinical and epidemiological level and tries to answer these questions.

Physical activity and other health-related factors predict health care utilisation in older adults: the ActiFE Ulm study.

BACKGROUND: Health care utilisation (HCU) can be a useful outcome for estimating costs and patient needs. It can also be used as a surrogate parameter for healthy ageing. The aim of this study was to analyse the associations of formerly described and potentially new parameters influencing health care utilisation in older adults in Germany. PATIENTS AND METHODS: The ActiFE Ulm (Activity and Function in the Elderly in Ulm) study is a population-based study in 1,506 community dwelling older adults aged 65-90 years in Ulm and surrounding areas in southwestern Germany. Between March 2009 and April 2010 a full geriatric assessment was performed including accelerometer-based average daily walking duration, comorbidity, medication, physical and psychological functioning, health care utilisation, sociodemographic factors etc. The association between above named measures and health care utilisation, represented by the number of drugs, the days in hospital and the number of physician contacts over one year was calculated in multiple regression models. Analysis was conducted among subjects with complete information (n = 1,059, mean age 76 years, 55% male). RESULTS: The average number of drugs was 4.5 and over 95% of participants visited a physician at least once a year while still more than 65% contacted their physician more than twice a year. Reduced physical activity, BMI, self-rated health and/or comorbidity and male sex were the best predictors of health care utilisation in community dwelling older adults when looking at both the number of drugs and the number of physician contacts over 12 months together. With regard to single diseases entities the best predictors of both the number of drugs and the number of physician contacts were asthma, chronic obstructive pulmonary disease (COPD)/chronic bronchitis and chronic neurological diseases (mostly Parkinson's disease). The number of drugs was most strongly associated with coronary heart disease, diabetes, and high blood pressure. CONCLUSION: Reduced walking activity, self-rated health and/or comorbidity and male sex are the best predictors of health care utilisation as measured by the number of drugs and number of physician contacts over 12 months. Walking activity could be regarded as the most promising modifiable predictor of HCU in older adults.

Pain and dementia: a diagnostic challenge.

PURPOSE: The aim was to present current knowledge about pain assessment in people with dementia and to discuss special challenges and possible solutions. METHODS: A literature search in MEDLINE® was performed. RESULTS: Due to the changing demographics of an aging population, an increasing number of people with dementia is expected. Many of these people will simultaneously suffer pain. Under-detection and under-treatment of pain in persons suffering from dementia is often described. As dementia progresses, the ability of the sufferer to verbally communicate his/her pain is often compromised, complicating the task of recognizing and treating pain. To improve pain recognition in dementia, many pain assessment tools have been developed. However, psychometric properties have to date been insufficiently examined. IMPLICATIONS: Self-report ratings should be performed as long as justifiable. Behavioural pain assessment tools should be used in advanced dementia despite their current imperfections: in particular, the PAINAD for daily use and the PACSLAC at longer intervals. All available additional information about pain should be considered.

[Maintenance of health and relief for caregivers of elderly with dementia by using "initial case management": experiences from the Lighthouse Project on Dementia, Ulm, ULTDEM-study]. / Gesunderhaltung und Entlastung pflegender Angehöriger von Demenzkranken durch ein "initiales Case Management": Erfahrungen aus dem Ulmer Leuchtturmprojekt Demenz (ULTDEM-Studie).

BACKGROUND: When facing the well-known demographic development with an increasing number of people suffering from dementia, there is a need of programmes to support nursing relatives and care at home. Many support services have been established in the past few years but they are rarely used by the relatives and the patients. The purpose of the Lighthouse Project Ulm (ULTDEM Study) was to prove the effectiveness of a single advisory approach in order to provide support services after care level classification and to relieve the burden placed on relatives caring for family members suffering from dementia ("initial case management"). METHODS: The ULTDEM Study is a prospective, open, randomized, controlled, interventional study with different parallel outcome measures (burden of caring, quality of life and mood). After the randomization, the interventional group was given comprehensive, individual advice about available treatment possibilities for dementia patients. Control group participants received standard treatment. Inclusion criteria were application of a care level (0 or 1) as well as dementia diagnosis. All participants (patients/relatives) underwent an initial and a 6 month comprehensive assessment. RESULTS: Our results show that a single advisory approach does not lead to a significant difference in outcome measures in interventional and control groups. Those tendencies described have to be interpreted as clinically not relevant. Although utilization of support services increases, it remains similar in both study groups. A confirmatory interpretation has not been possible due to a lack of adjustment to the findings regarding multiple testing and an insufficient degree of recruitment. Possible causes will be discussed such as premature intervention during the course of the disease, a lack of intervention blinding, recruitment bias and lack of an influence on adherence with regard to the use of support services. IMPLICATIONS: The study demonstrates that there is a substantial information deficit for persons affected by dementia and their relatives. Innovative ways still have to be developed to ensure that this information actually reaches the target audience.

Efficacy and safety of pharmacotherapy for Alzheimer's disease and for behavioural and psychological symptoms of dementia in older patients with moderate and severe functional impairments: a systematic review of controlled trials.

BACKGROUND: Many patients with Alzheimer's disease (AD) are physically frail or have substantial functional impairments. There is growing evidence that such patients are at higher risk for medication-induced adverse events. Furthermore, frailty seems to be more predictive of poor clinical outcomes than chronological age alone. To our knowledge, no systematic review of clinical trials examining drug therapy of AD or behavioural and psychological symptoms of dementia (BPSD) has specifically focused on the topic of physical frailty. Our objective was to evaluate the efficacy and safety of pharmacotherapy in AD patients with frailty or significant functional impairments. METHODS: We performed a systematic literature search in MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) for randomized controlled trials (RCTs) of drug therapy of AD and BPSD in patients with significant functional impairments according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Cochrane research criteria. Significant functionally impaired patient populations were identified using the recommendations of the Medication and Quality of Life in frail older persons (MedQoL) Research Group. Screening, selection of studies, data extraction and risk of bias assessment were performed independently by two reviewers. Outcomes including functional status, cognitive function, changes in BPSD symptoms, clinical global impression and quality of life were analysed. For assessing harm, we assessed adverse events, drop-outs as a proxy for treatment tolerability and death. Results were analysed according to Cochrane standards and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: Of 45,045 search results, 38,447 abstracts and 187 full texts were screened, and finally, 10 RCTs were included in the systematic review. Selected articles evaluated pharmacotherapy with acetylcholinesterase-inhibitors (AChEI), anticonvulsants, antidepressants and antipsychotics. Studies of AChEIs suggested that patients with significant functional impairments had slight but significant improvements in cognition and that AChEIs were generally well tolerated. Studies of antidepressants did not show significant improvements in depressive symptoms. Antipsychotics and anticonvulsants showed small effects on some BPSD items but also higher rates of adverse events. However, due to the very small number of identified trials, the quality of evidence for all outcomes was low to very low. Overall, the small number of eligible studies demonstrates that significantly functional impaired older patients have not been adequately taken into consideration in most clinical trials investigating drug therapy of AD and BPSD. CONCLUSION: Due to lack of evidence, it is not possible to give specific recommendations for drug therapy of AD and BSPD in frail older patients or older patients with significant functional impairments. Therefore, clinical trials focussing on frail older adults are urgently required. A standardized approach to physical frailty in future clinical studies is highly desirable.

A Propensity Score Matched Approach to Assess the Associations of Commonly Prescribed Medications with Fall Risk in a Large Harmonized Cohort of Older Ambulatory Persons.

INTRODUCTION: Several medication classes are considered to present risk factors for falls. However, the evidence is mainly based on observational studies that often lack adequate adjustment for confounders. Therefore, we aimed to assess the associations of medication classes with fall risk by carefully selecting confounders and by applying propensity score matching (PSM). METHODS: Data from several European cohorts, harmonized into the ADFICE_IT cohort, was used. Our primary outcome was time until the first fall within 1-year follow-up. The secondary outcome was a fall in the past year. Our exposure variables were commonly prescribed medications. We used 1:1 PSM to match the participants with reported intake of specific medication classes with participants without. We constructed Cox regression models stratified by the pairs matched on the propensity score for our primary outcome and conditional logistic regression models for our secondary outcome. RESULTS: In total, 32.6% of participants fell in the 1-year follow-up and 24.4% reported falling in the past year. ACE inhibitor users (prevalence of use 15.3%) had a lower fall risk during follow-up when matched to non-users, with a hazard ratio (HR) of 0.82 (95% CI 0.68-0.98). Also, statin users (prevalence of use 20.1%) had a lower risk, with an HR of 0.76 (95% CI 0.65-0.90). Other medication classes showed no association with risk of first fall. Also, in our secondary outcome analyses, statin users had a significantly lower risk. Furthermore, ß-blocker users had a lower fall risk and proton pump inhibitor use was associated with a higher risk in our secondary outcome analysis. CONCLUSION: Many commonly prescribed medication classes showed no associations with fall risk in a relatively healthy population of community-dwelling older persons. However, the treatment effects and risks can be heterogeneous between individuals. Therefore, focusing on identification of individuals at risk is warranted to optimize personalized falls prevention.

Standard treatment of female patients with breast cancer decreases substantially for women aged 70 years and older: a German clinical cohort study.

BACKGROUND: Standard treatment of patients with breast cancer decreases with age and older persons are mostly excluded from clinical trials. We hypothesized that non-adherence to treatment guidelines occurs for women aged > or =70 years and changes overall survival (OAS) and disease-free survival (DFS). PATIENTS AND METHODS: We enrolled 1922 women aged > or =50 years with histologically confirmed invasive breast cancer treated at the University of Ulm from 1992 to 2005. Adherence to guidelines and effects on OAS and DFS for women aged > or =70 years was compared with that for younger women (50-69 years). RESULTS: Women >70 years less often received recommended breast-conserving therapy (70-79 years: 74%-83%; >79 years: 54%) than women aged < or =69 years (93%). Non-adherence to the guidelines on radiotherapy (<70 years: 9%; 70-79 years: 14%-27%; >79 years: 60%) and chemotherapy (<70 years: 33%; 70-79 years: 54%-77%; > 79 years: 98%) increased with age. Omission of radiotherapy significantly decreased OAS [< or =69 years: hazard ratio (HR) = 3.29; P <0.0001; > or =70 years: HR = 1.89; P = 0.0005] and DFS (< or =69 years: HR = 3.45; P <0.0001; > or =70 years: HR = 2.14; P <0.0001). OAS and DFS did not differ significantly for adherence to surgery, chemotherapy, or endocrine therapy. CONCLUSION: Our study confirms that substandard treatment increases considerably with age. Omission of radiotherapy had the greatest impact on OAS and DFS in the elderly population.

[Reliability of the abbreviated version of the Late Life Function and Disability Instrument--a meaningful and feasible tool to assess physical function and disability in the elderly]. / Reliabilität der deutschen Kurz-Version des "Late Life Function and Disability Instrument". Ein sinnvoller und praktikabler Fragebogen zur Bestimmung der körperlichen Funktion und Beeinträchtigung älterer Personen.

BACKGROUND: The early assessment of prevalent disability and functional decline is of increasing importance for prevention issues and for the evaluation of change in clinical studies. The assessment of common daily tasks and resulting disability is essential for a complete impression of a patient's capabilities. There are plenty of instruments that cover basic and instrumental activities of daily living by assessing the person's dependence at a specific functional task. However, the early stages of everyday life limitations and functional decline are usually not being captured. In this article we have examined psychometric properties of the German adaptation of the abbreviated "late life function and disability instrument", a promising tool that is capable of capturing early aspects of functional decline and disability. METHODS: Older Caucasian men and women (Median=82 years) with a wide range of functional status (Short Physical Performance Battery: Median=6, Min.=0, Max.=12) completed the abbreviated version of the LLFDI once (n=173). A subgroup was assessed twice to examine interrater (n=13) and intrarater (n=10) reliability. Cognitive and functional status was assessed at baseline. RESULTS: Internal consistency (Cronbach's ) was acceptable for the personal role and social role of the frequency items of the disability component (0.55 to 0.62) and very good for all other parts of the instrument (0.78 to 0.89) without a significant difference when compared for overall cognitive performance or executive function. Test-retest reliability was very good (0.81 to 0.96) and interrater reliability was acceptable to very good (0.62 to 0.96) with only acceptable results for the limitation items of the disability component. The total scores of the two components did not demonstrate significant floor or ceiling effects and the interview lasted on average 17 minutes (range 8 to 35 min). INTERPRETATION: The German adaptation of the abbreviated version of the "Late Life Function and Disability Instrument" has minimal ceiling and floor effects, acceptable to good internal consistency and interrater reliability, and very good test-retest reliability. Hence, it constitutes an excellent alternative to common self-rating instruments for the assessment of functional capacities in everyday activities.

[Master trainer concept "structured specialist further education" : A joint project of the German Professional Associations of Internal Medicine, Surgeons and Orthopedic/Trauma Surgeons]. / Mastertrainerkonzept "Strukturierte Facharztweiterbildung" : Ein gemeinsames Projekt der Deutschen Berufsverbände der Internisten, Chirurgen und Orthopäden/Unfallchirurgen.

BACKGROUND: The quality requirements in the practice of postgradual medical further education below the normal level of the further education regulations is a barely developed scientific field in Germany. A systematic use of internationally accepted scientific evidence barely exists. AIM: This research and development project was initiated in 2001 in order to be able to implement a practical but evidence-based model compatible with the existing structure of postgradual medical education. This project has been supported since 2013 by the Professional Associations of Internal Medicine (BDI), Surgeons (BDC) and Orthopedic and Trauma surgeons (BVOU). METHODS: The development phase of this complex intervention was based on three stages involving stakeholder interviews from relevant groups, the identification of a theoretical model for the construction and systematic literature reviews to identify the relevant evidence. RESULTS: The basic model for structured specialist further education developed included the creation and implementation of a simple core curriculum for every department, a tool for systematic feedback within the framework of the annual further education interviews and a simple clinical assessment to evaluate the actual clinical performance of physicians in further education. A pilot test of this model was carried out in 150 specialist departments in Germany and continually developed. DISCUSSION: The project shows that such a program can be systematically developed and pilot studies can be carried out. The central problems in implementation involve the traditional informal further education culture, which as a rule does not implement a systematic elicitation of the state of learning continuously distributed over the whole period of further education and the practical testing of competence development.

Evaluation of left and right ventricular systolic and diastolic electromechanical synchrony in older people: a population-based observational study.

It is unknown whether physiological ageing also goes along with electromechanical asynchrony of contraction. Aim of the study was to evaluate synchrony of contraction in older people with ("non-healthy") or without ("healthy") evidence for structural cardiac disease. In 547 persons (age 76.7+/-5.5 years, 306 male, 241 female) recruited from a population-based cohort of the ActiFE-Ulm study including a random sample of people >/=65 years old living in the region of Ulm, Germany, various PW- and TDI-Doppler based markers for asynchrony were obtained by echocardiography. Within a subgroup of 84 healthy subjects, at most minimal systolic and diastolic asynchrony was found. Concerning systolic asynchrony, similar observations were made within the non-healthy subgroup. However, extent of diastolic left ventricular intraventricular asynchrony and also - by tendency - diastolic interventricular asynchrony was increased in comparison to the healthy subgroup. To conclude, no evidence that physiological ageing might go along with relevant left or right ventricular systolic or diastolic electromechanical asynchrony was found in our study. Furthermore, our population-based data support the results from other clinical studies with rather selected cohorts that structural heart diseases might go along with increased diastolic asynchrony.

Availability and use of neighborhood resources by older people with osteoarthritis: Results from the European Project on OSteoArthritis.

This study examines the availability and use of neighborhood resources in relation to clinical lower limb osteoarthritis (LLOA) in older participants from six European countries. Of the 2757 participants (65-85 years), 22.7% had LLOA. Participants with LLOA made more use of places to sit (OR=2.50; CI: 1.36-4.60 in the UK), and less use of parks and walking areas (OR=0.30; CI: 0.12-0.75 in Sweden), compared to participants without LLOA, particularly in countries with high availability of resources. The results suggest that specific features of the environment impact the use of neighborhood resources by older adults with LLOA.