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Aims: To find factors that are associated with a general practitioner's (GP's) subjective impression of a patient being 'difficult' within a sample of patients with type 2 diabetes mellitus (T2DM).Methods: Secondary cross-sectional analysis of a cohort of GP patients with T2DM. GP questionnaire on clinical data and GPs' subjective ratings of patient attributes (including 'patient difficulty'). Patient questionnaire on sociodemographics and illness perceptions. Bivariate and multivariate analyses, adjusted for cluster-effect of GP practice.Results: Data from 314 patients from 49 GPs could be analysed. Independent associations with higher GP-rated difficulty were found for (odds ratio; 95% confidence interval): male patients from male GPs (1.27; 1.06-1.53), unmarried men (1.25; 1.04-1.51), men with non-German nationality (1.80; 1.24-2.61), patients perceiving more problems with diabetes (1.17; 1.04-1.30), patients with higher BMI (1.01; 1.00-1.02) and HbA1c values (1.06; 1.02-1.10), patients being perceived by the GP as less adherent (1.34; 1.22-1.46) and less health-literate (1.19; 1.04-1.35).Conclusions: The impact of patients' gender and illness perception yield new insights into GP-perceived complexity of care. Culturally and gender-sensitive communication techniques for adapting health care goals to patients' problems (rather than norm values) may alleviate GPs' work. [ABSTRACT FROM AUTHOR]

The article discusses research which was conducted to investigate the diagnostic accuracy of the Total Score of the Consortium to Establish a Registry for Alzheimer’s Disease neuropsychological assessment battery (CERAD-NP) and its ability to diagnose Alzheimer disease dementia. Researchers evaluated the battery with 1,606 people with a mean age of 84 years. They found that the battery was a highly accurate diagnostic tool.

Objectives: There is an increasing call for a stronger consideration of impairment in instrumental activities of daily living (IADL) in the diagnostic criteria of Mild Cognitive Impairment (MCI) to improve the prediction of dementia. Thus, the aim of the study was to determine the predictive capability of MCI and IADL impairment for incident dementia. Design: Longitudinal cohort study with four assessments at 1.5-year intervals over a period of 4.5 years. Setting: Primary care medical record registry sample. Participants: As part of the German Study on Ageing, Cognition, and Dementia in Primary Care Patients, a sample of 3,327 patients from general practitioners, aged 75 years and omen, was assessed. Measurements: The predictive capability of MCI and IADL impairment for incident dementia was analysed using receiver operating characteristics, Kaplan-Meier survival analyses, and Cox proportional hazards models. Results: MCI and IADL impairment were found to be significantly associated with higher conversion to, shorter time to, and better predictive power for future dementia. Regarding IADL, a significant impact was particularly found for impairment in responsibility for one's own medication, shopping, and housekeeping, and in the ability to use public transport. Conclusions: Combining MCI with IADL impairment significantly improves the prediction of future dementia. Even though information on a set of risk factors is required to achieve a predictive accuracy for dementia in subjects with MCI being clinically useful, IADL impairment should be a very important element of such a risk factor set. [ABSTRACT FROM AUTHOR]

Objectives: The Consortium to Establish a Registry for Alzheimer's Disease-Neuropsychological (CERAD-NP) battery represents a commonly used neuropsychological instrument to measure cognitive functioning in the elderly. This study provides normative data for changes in cognitive function that normally occur in cognitively healthy individuals to interpret changes in CERAD-NP test scores over longer time periods. Design: Longitudinal cohort study with three assessments at 1.5-year intervals over a period of 3 years. Setting: Primary care medical record registry sample. Participants: As part of the German Study on Ageing, Cognition, and Dementia in Primary Care Patients, a sample of 1,450 cognitively healthy general practitioner patients, age 75 years and older, was assessed. Measurements: Age-, education-, and gender-specific Reliable Change Indices (RCIs) were computed for a 90% confidence interval for selected subtests of the CERAD-NP battery. Results: Across different age, education, and gender subgroups, changes from at least six to nine points in Verbal Fluency, four to eight points in Word List Memory, two to four points in Word List Recall, and one to four points in Word List Recognition indicated significant (i.e. reliable) changes in CERAD-NP test scores at the 90% confidence level. Furthermore, the calculation of RCIs for individual patients is demonstrated. Conclusions: Smaller changes in CERAD-NP test scores can be interpreted with only high uncertainty because of probable measurement error, practice effects, and normal age-related cognitive decline. This study, for the first time, provides age-, education-, and gender-specific CERAD-NP reference values on the basis of RCI methods for the interpretation of cognitive changes in older-age groups. [ABSTRACT FROM AUTHOR]

Objectives: To assess the accuracy of the General Practitioner's (GP) judgment in the recognition of incident dementia cases and to explore factors associated with recognition. Design: Prospective observational cohort study, two follow-up assessments (FU I and FU 2) within 3 years after baseline. Setting: One hundred thirty-eight general practice surgeries in the six study centers of a prospective German study. Participants: Participants were between 75 and 89 years of age at baseline and were recruited from the GPs' patient lists. In FU 1, 2,402 patients and in FU 2, 2,177 patients were analyzed. Measurements: GPs' judgments on their patients' cognitive status as index test at-home patient interviews and tests, consensus diagnosis as reference; validity of the GP judgment associations between patient factors and GPs' dementia recognition. Results: One hundred eleven incident dementia cases with complete data were identified in FU 1 and FU 2. Overall sensitivity of the GP judgment was 51.4%, specificity 95.9%, positive predictive value 23.6%, and negative predictive value 98.8%. GPs missed dementia more frequently in patients living alone. GPs overrated the presence of dementia more frequently in patients with problems in mobility or hearing, in patients with memory complaints, and in patients with a GP-documented depression. Conclusion: GPs miss nearly half of incident dementia cases. They should be alert not to miss dementia in patients living alone. Without seeking additional information, a positive GP judgment seems not sufficient for case finding. GPs should be aware of their tendency to overestimate dementia in depressed and frail patients. [ABSTRACT FROM AUTHOR]

Objective: To identify inter-individual examiner factors associated with interrater reliability in a summative communication OSCE in the 4th study year.Methods: The OSCE consists of 4 stations assessed with a 4-item 5-point global rating instrument. A bivariate secondary analysis of interrater reliability in relation to 4 examiner factors (gender, profession, OSCE experience, examiner training) was conducted. Intraclass correlation coefficients (ICC) were calculated and compared between examiner dyads of different similarity.Results: 169 pairwise ratings from 19 different examiners in 16 dyads were analysed. Interrater reliability is significantly higher in examiner dyads of same vs. different gender (ICC=0.76 (95%CI=0.65-0.83) vs. ICC=0.41 (95%CI=0.21-0.57)), in dyads of two clinicians vs. non-clinical/mixed professions (ICC=0.72 (95%CI=0.56-0.83) vs. ICC=0.57 (95%CI=0.41-0.69)), and in dyads with high vs. low/mixed OSCE experience (ICC=0.73 (95%CI 0.50-0.87) vs. ICC=0.56 (95%CI=0.41-0.69)). Participation in recent examiner training had no influence on ICCs.Conclusion: Better concordance of ratings between clinically active examiners might be a hint for context specificity of good communication. Higher interrater reliability between examiners with same gender may indicate gender-specific communication concepts.Practice Implications: Medical faculties introducing summative assessment of communication competence should focus the influence of examiner characteristics on interrater reliability. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To evaluate the summative assessment (OSCE) of a communication training programme for dealing with challenging doctor-patient encounters in the 4th study year. METHODS: Our OSCE consists of 4 stations (breaking bad news, guilt and shame, aggressive patients, shared decision making), using a 4-item global rating (GR) instrument. We calculated reliability coefficients for different levels, discriminability of single items and interrater reliability. Validity was estimated by gender differences and accordance between GR and a checklist. RESULTS: In a pooled sample of 456 students in 3 OSCEs over 3 terms, total reliability was [alpha]=0.64, reliability coefficients for single stations were >0.80, and discriminability in 3 of 4 stations was within the range of 0.4-0.7. Except for one station, interrater reliability was moderate to strong. Reliability on item level was poor and pointed to some problems with the use of the GR. CONCLUSION: The application of the GR on regular undergraduate medical education shows moderate reliability in need of improvement and some traits of validity. Ongoing development and evaluation is needed with particular regard to the training of the examiners. PRACTICE IMPLICATIONS: Our CoMeD-OSCE proved suitable for the summative assessment of communication skills in challenging doctor-patient encounters. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To compare the costs of care for community-dwelling dementia patients with the costs of care for dementia patients living in nursing homes from the societal perspective. Design: Cross-sectional bottom-up cost of illness study nested within the multicenter German AgeCoDe-cohort. Setting: Community and nursing homes. Participants: One hundred twenty-eight community-dwelling dementia patients and 48 dementia patients living in nursing homes. Intervention: None. Measurements: Utilization and costs of medical care and long term care, including formal and informal social and nursing care based on proxy interviews. Informal care was valued using the replacement cost method. Results: Unadjusted mean annual total costs including informal care were €29,930 ($43,997) for community-dwelling patients and €33,482 ($49,218) for patients living in nursing homes. However, multiple regression analysis controlling for age, sex, deficits in basic and instrumental activities of daily living and comorbidity showed that living in the community significantly increased total costs by €11,344 ($16,676; P < .01) compared with living in a nursing home, mainly due to higher costs of informal care (+€20,585; +$30,260; P < .001). Conclusion: From the societal perspective care for dementia patients living in the community tends to cost more than care in nursing homes when functional impairment is controlled for. [Copyright &y& Elsevier]

There is a lack of studies disentangling whether changes in frailty are associated with subsequent changes in depressive symptoms or vice versa among the oldest old. Consequently, we aimed to disentangle this link. Three waves [follow-up (FU) wave 7 to FU wave 9; n = 423 individuals 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+)" (AgeQualiDe). Primary care patients aged 85 years and older. The Canadian Study of Health and Aging (CSHA) Clinical Frailty Scale (CFS) was used to quantify frailty, and the Geriatric Depression Scale was used to measure depressive symptoms. It was adjusted for several covariates (sociodemographic and health-related factors) in regression analysis. Multiple linear regressions with first differences showed that initial increases in depressive symptoms (from FU wave 7 to FU wave 8) were associated with subsequent increases in frailty (from FU wave 8 to FU wave 9; β = 0.06, P <.05), whereas initial increases in frailty (from FU wave 7 to FU wave 8) were not associated with subsequent increases in depressive symptoms (from FU wave 8 to FU wave 9). The study findings suggest the relevance of increases in depressive symptoms for subsequent increases in frailty. Treatment of depressive symptoms may also be beneficial to postpone frailty. [ABSTRACT FROM AUTHOR]