[Profiling of patients in a specialized geriatric outpatient clinic]. / Profilanalyse ambulanter Patienten einer geriatrischen Spezialsprechstunde.

BACKGROUND: In Germany geriatric outpatient care is predominantly done by family doctors and general practitioners (GP). There are regionally different concepts for additional specialized geriatric outpatient care but they have not yet been validated and established. Still, it remains unclear whether a geriatric patient has to be diagnosed rather in a specialized outpatient or inpatient setting. The aim of the present study is the profiling of geriatric outpatients to find key distinctions from geriatric patients that have to be admitted to hospital. METHODS: Retrospective data analysis of patients sent to a specialized geriatric outpatient clinic by their GP, compared with data of geriatric inpatients sent to hospital by their GP during the same time period. Study parameters comprised elements of the comprehensive geriatric assessment as well as results of routinely applied laboratory tests. RESULTS: Patients sent to the specialized geriatric outpatient clinic showed better results of functional assessments. Regression analysis: improvement of Barthel Index, GFR and total protein increased the chance of outpatient treatment. CONCLUSION: Early identification of geriatric patients who can be treated in a specialized outpatient setting would ease the burden for GPs by interdisciplinary cooperation and prevent cost-intensive readmissions to hospital.

Psychotherapeutic case formulation: Plan analysis for narcissistic personality disorder.

BACKGROUND: One of the relevant case formulation methods for personality difficulties is plan analysis. The present study aimed at delivering a prototypical plan analysis for clients presenting with a diagnosis of narcissistic personality disorder (NPD). The sample consisted of 14 participants diagnosed with an NPD. Based on audio clinical material, we developed 14 individual plan analyses that we then merged into a single prototypical plan analysis. For explorative purposes, we ran an ordinary least squares regression model to predict the narcissistic symptoms severity (NAR) measured on a scale of 1-7 of the 14 clients by the presence (respectively absence) of certain plans in their individual plan analysis. The synthesis revealed that clients with pathological narcissism share common basic motives. Results of the regression model reveal that the presence of the plan 'be strong' reduces the NAR scale by 1.52 points (p = 0.011). DISCUSSION: In the treatment of psychological disorders, precise case formulations allow therapists for making clinically appropriate decision, personalizing the intervention and gaining insight into the client's subjective experience. In the prototypical plan structure we developed for NPD, clients strive to strengthen their self-esteem and avoid loss of control, criticism and confrontation as well as to get support, understanding and solidarity. When beginning psychotherapy with a client presenting with NPD, the therapist can use these plans as valuable information to help writing tailored, and therefore more efficient, case formulations for their patients presenting with an NPD.

[Outpatient care for the old and very old]. / Ambulante Versorgung älterer und hochaltriger Patienten.

BACKGROUND: Outpatient treatment of elderly patients is the responsibility of the family doctor. In addition to general practitioner care, there are some regionally different models that are currently not established and evaluated in Germany. The investigation presented here aims to contribute to the profiling of outpatient geriatric care in the future. METHOD: A full survey on the attitude and acceptance of general practitioners towards outpatient geriatrics and a geriatric focus practice was carried out. At the same time, referral and advisory events were systematically recorded and compared. RESULTS AND CONCLUSION: A geriatric focus practice can complement primary care. It is well accepted by many family doctors if there is a transparent exchange, pilot function and basic family doctor activities remain with the family doctor and he is relieved of the burden on complex patients.

Long-term effect of exercise training in patients after transcatheter aortic valve implantation: Follow-up of the SPORT:TAVI randomised pilot study.

Background Increased exercise capacity favourably influences clinical outcomes after transcatheter aortic valve implantation. In our SPORT:TAVI randomised pilot trial, eight weeks of endurance and resistance training (training group, TG) shortly after transcatheter aortic valve implantation resulted in significantly improved exercise capacity, muscular strength and quality of life compared to usual care (UC). However, the long-term clinical benefits of such an intervention are unknown. Design A randomised controlled trial. Methods SPORT:TAVI participants underwent reassessment of trial endpoints 24 ± 6 months after baseline: maximal oxygen uptake (VO2peak) and anaerobic threshold (VO2AT) were assessed with cardiopulmonary exercise testing, muscular strength with one-repetition maximum testing, quality of life with the Kansas City cardiomyopathy and medical outcomes study 12-item short-form health survey questionnaires, and prosthetic aortic valve function with echocardiography. Results Of 27 original participants (TG 13; UC 14; age 81 ± 6 years), more patients had died during follow-up in UC ( n = 5) than in TG ( n = 2; P = 0.165); three further patients (TG 1; UC 2) were unavailable for other reasons. In the remaining patients (TG 10; UC 7), a significant between-group difference in favour of TG was observed for change in VO2AT from baseline (2.7 ml/min/kg (95% confidence interval 0.8-4.6); P = 0.008), but not for change in VO2peak (2.1 ml/min/kg (-1.1-5.4); P = 0.178). Changes in muscular strength and quality of life did not differ between groups over time. Overall, prosthetic valve function remained intact in both groups. Conclusions Eight weeks of exercise training shortly after transcatheter aortic valve implantation resulted in preserved long-term improvements in VO2AT, but not VO2peak, muscular strength or quality of life compared to usual care. The findings emphasise the importance of ongoing exercise interventions following transcatheter aortic valve implantation to maintain initial improvements long term. Clinical Trial Registration (original trial): Clinicaltrials.gov NCT01935297.

AIDE-Acute Illness and Depression in Elderly Patients. Cognitive Behavioral Group Psychotherapy in Geriatric Patients With Comorbid Depression: A Randomized, Controlled Trial.

BACKGROUND: Comorbid depression is highly prevalent in geriatric patients and associated with functional loss, frequent hospital re-admissions, and a higher mortality rate. Cognitive behavioral psychotherapy (CBT) has shown to be effective in older depressive patients living in the community. To date, CBT has not been applied to older patients with acute physical illness and comorbid depression. OBJECTIVES: To evaluate the effectiveness of CBT in depressed geriatric patients, hospitalized for acute somatic illness. DESIGN: Randomized controlled trial with waiting list control group. SETTING: Postdischarge intervention in a geriatric day clinic; follow-up evaluations at the patients' homes. PARTICIPANTS: A total of 155 randomized patients, hospitalized for acute somatic illness, aged 82 ± 6 years and suffering from depression [Hospital Anxiety and Depression Scale (HADS) scores >7]. Exclusion criteria were dementia, delirium, and terminal state of medical illness. INTERVENTION: Fifteen, weekly group sessions based on a CBT manual. Commencement of psychotherapy immediately after discharge in the intervention group and a 4-month waiting list interval with usual care in the control group. MEASUREMENTS: HADS depression total score after 4 months. Secondary endpoints were functional, cognitive, psychosocial and physical status, resource utilization, caregiver burden, and amount of contact with physician. RESULTS: The intervention group improved significantly in depression scores (HADS baseline 18.8; after 4 months 11.4), whereas the control group deteriorated (HADS baseline 18.1; after 4 months 21.6). Significant improvement in the intervention group, but not in the control group, was observed for most secondary outcome parameters such as the Barthel and Karnofsky indexes. Intervention effects were less pronounced in patients with cognitive impairment or acute fractures. CONCLUSIONS: CBT is feasible and highly effective in geriatric patients. The benefits extend beyond effective recovery and include improvement in physical and functional parameters. Early diagnosis, good access to psychotherapy, and early intervention could improve care for depressive older patients. CLINICAL TRIAL REGISTRATION: www.germanctr.de German Trial Register DRKS 00004728.

[The patient under antidepressive and antipsychotic therapy]. / Der Patient unter antidepressiver und antipsychotischer Therapie. Was Sie als Hausarzt wissen müssen.

The family physician is responsible for the primary medical care of a mentally ill person. Because these patients are frequently treated with antidepressants or antipsychotic drugs, the family physician should be well-informed of the indication, dosage and side effects of these substances. Among antidepressants, selective serotonin reuptake inhibitors (SSRI) and newer substances usually have a more favorable side effect profile than tricyclic antidepressants (TCA). Atypical antipsychotic drugs show a lower risk for extrapyramidal motor disorders in contrast to conventional antipsychotic drugs. Undesired effects such as weight gain can, however, occur in all substance groups. The treatment of somatic comorbidities in these mentally ill patients and, likewise, the prophylaxis to prevent recurrence of depressive and schizophrenic diseases are also the responsibility of the family physician.

Psychological insulin resistance in geriatric patients with diabetes mellitus.

OBJECTIVE: To determine the extent to which geriatric patients with diabetes mellitus experience psychological insulin resistance (PIR). METHODS: A total of 67 unselected geriatric patients with diabetes (mean age 82.8±6.7 years, diabetes duration 12.2 [0.04-47.2] years, 70.1% female) were recruited in a geriatric care center of a university hospital. A comprehensive geriatric assessment (CGA) was performed including WHO-5, Hospital Anxiety and Depression Scale (HADS), Mini Mental State Examination (MMSE) and Barthel-Index. We assessed PIR using the Barriers of Insulin Treatment Questionnaire (BIT) and the Insulin Treatment Appraisal Scale in a face-to-face interview. RESULTS: Insulin-naïve patients (INP) showed higher PIR scores than patients already on insulin therapy (BIT-sum score: 4.3±1.4 vs. 3.2±1.0; p<0.001). INP reported in the BIT increased fear of injection and self-testing (2.4±2.4 vs. 1.3±0.8; p=0.016), expect disadvantages from insulin treatment (2.7±1.6 vs. 1.9±1.4; p=0.04), and fear of stigmatization by insulin injection (5.2±2.3 vs. 3.6±2.6; p=0.008). Fear of hypoglycemia, however, did not differ significantly (6.3±2.8 vs. 5.1±3.1; p=0.11). Depression was not shown to be a barrier to insulin therapy. CONCLUSION: INP with diabetes have a significantly more negative attitude toward insulin therapy in comparison to patients already on insulin. PRACTICE IMPLICATIONS: Systematic assessment of barriers of insulin therapy, individualized diabetes treatment plans and information of patients may help to overcome such negative attitudes, leading to quicker initiation of therapy, improved adherence to treatment and a better quality of life.

Serum lipoproteins improve after successful pharmacologic antidepressant treatment: a randomized open-label prospective trial.

OBJECTIVE: Despite reports of lower plasma cholesterol in depressed patients, major depressive disorder has been shown to increase cardiovascular risk. Our objective was to study the composition of lipoproteins in depressed patients and controls and to examine the effects of pharmacologic treatment and treatment response on lipoprotein composition. METHOD: Lipoprotein composition was analyzed in 65 adult inpatients at a university psychiatric hospital in Germany with DSM-IV major depressive disorder and 33 healthy controls (recruited via newspaper and radio ads) matched for age and sex. After the cross-sectional study phase, the patients were randomized in an open-label prospective trial to treatment with either mirtazapine or venlafaxine. Lipoproteins were reanalyzed after 4 weeks of treatment. Main outcome measures were total cholesterol, the low-density lipoprotein (LDL) to high-density lipoprotein (HDL) cholesterol ratio, and the LDL triglycerides to apolipoprotein B ratio. Secondary outcome measures were total triglycerides, HDL and LDL cholesterol levels, and apolipoproteins A1 and B levels. Comparisons were made between the 2 drug groups and between remitters and nonremitters as measured by the 21-item Hamilton Depression Rating Scale. The study was conducted from April 2003 through December 2007. RESULTS: Total cholesterol at baseline was lower in patients than in controls (mean ± SD = 4.99 ± 0.98 mmol/L vs 5.63 ± 1.01 mmol/L; P = .003), with significantly lower HDL cholesterol (P < .001) and LDL cholesterol (P = .03) in patients. However, the ratio of LDL triglycerides to apolipoprotein B, an index of size and atherogenic potential of LDL particles, was higher in depressed subjects (mean ± SD = 0.46 ± 0.14 mmol/g vs 0.38 ± 0.09 mmol/g; P = .002). Irrespective of treatment allocation, we found significant improvement of cardiovascular risk parameters in remitters but found deterioration in nonresponders. The LDL cholesterol mean change from baseline (remitters vs partial responders vs nonresponders) was -0.06 mmol/L versus +0.39 mmol/L versus +0.56 mmol/L (P = .014); the mean change in LDL/HDL cholesterol ratio was -0.50 versus +0.14 versus +0.80 (P = .002); and the mean change in the LDL triglycerides per apolipoprotein B ratio was -0.01 versus -0.01 versus +0.08 (P = .045). No drug-specific changes in lipid concentrations during treatment were observed except for total cholesterol (venlafaxine group mean = -0.02 mmol/L and mirtazapine group mean = +0.37 mmol/L; P = .033). CONCLUSIONS: In depressed patients, lipoprotein structure is changed toward LDL particles with a higher atherogenic potential. Remission from depression is associated with an improvement of the LDL/HDL cholesterol ratio, shifting lipoproteins toward a less atherogenic composition. Our findings should be confirmed in a larger study, as they have relevance for both researchers and clinicians. TRIAL REGISTRATION: German Clinical Trial Registry Identifier: DRKS00000008.