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ObjectivesApathy is a neuropsychiatric symptom in mild cognitive impairment (MCI) and dementia. This study examines correlations between Apathy Evaluation Scale (AES) ratings and actigraphic measures of daytime activity. The aim of this study is to determine the value of ambulatory actigraphy in the assessment of locomotor deficits as a correlate of apathy in geriatric patients with cognitive impairment.Patients and methodsIn this cross-sectional study a total of 82 participants were recruited, 32 patients with dementia, 21 patients with MCI and 23 elderly controls. Rating scales for apathy (AES) and depression (Beck Depression Inventory, BDI) were completed. To measure daytime activity a wrist-worn actigraph and an established protocol were used. A single measure of mean daytime activity per participant was calculated for further statistical analysis.ResultsIn the two groups of patients with MCI and dementia, apathy is associated with reduced daytime activity, independent of diagnosis (no group by apathy interaction). AES scores correlate significantly with daytime activity. Cognitive impairment reduces daytime activity (effect greater in dementia than in MCI). Daytime activity is negatively correlated with memory deficits.ConclusionAmbulatory actigraphy is a promising method to evaluate self-initiated action as a correlate of apathy in patients with cognitive impairment.

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.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.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.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 units20 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 concentrations50 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.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.

To determine predictors of death, nursing home placement and hospital admission, a prospective study was carried out in a university-affiliated geriatric hospital and a general practice. One hundred and thirty-five patients consecutively admitted from home to the geriatric hospital and discharged home again (site 1), and 144 patients, aged 70 years and over, of a general practice (site 2) were recruited for a comprehensive geriatric assessment program. At baseline, none was completely dependent on others, or severely demented. At follow-up after 18 months, 46 subjects (17%) had died, 20 subjects (7%) had been institutionalized, and 79 had been admitted to hospital (28 %) in the interim. Univariate analysis demonstrated a significant association between Barthel Activities of Daily Living (ADL), Lawton-Brody Instrumental Activities of Daily Living (IADL), Mini-Mental State Examination (MMSE), Balance and Gait Evaluation, Timed “Up and Go”, Timed Test of Money Counting, Grip-Strength and Williams Board Test, and death as well as nursing home placement. Barthel-ADL were significantly correlated with hospital admission. In a logistic regression analysis, Barthel-ADL were independent predictors for death; Barthel-ADL, Timed “Up and Go”, Timed Test of Money Counting, and Williams Board Test were independent predictors for nursing home placement. No independent predictor was found for hospital admission. It is concluded that self-report and performance-based measures of functional capabilities are useful instruments to identify patients at risk for nursing home placement and death. Factors contributing to hospital admissions are other than those measured by the applied tests.

Objectives: To examine medication problems during a stay in hospital and after discharge and to identify risk factors that contribute to poor compliance with medication a prospective observational study was carried out in an university-affiliated geriatic hospital and a patients' home. Patients: One hundred and nineteen patients admitted from home to the geriatric hospital underwent a comprehensive geriatric assessment. They were also tested in opening and removing tablets from various common medicine containers. Drug prescriptions before, during and after the hospital stay were recorded. Medication use at home was observed by a member of a hospital-based home intervention team. The patients' reports of their drug therapy was compared with those by their family doctors. Results: Of all tested patients 10.1% failed to open at least one container. This inability was associated with poor vision, impaired cognitive function and low manual dexterity. Compliance with prescribed medication was associated with cognitive function, ability to handle medication containers, number of prescribed drugs and recent changes in drug prescriptions. Of the patients only 39.5% had stable drug prescriptions during the 3-month study period. Doctor/patient agreement concerning drug therapy was low in all age groups. The agreement rate and patients' knowledge of their treatment was correlated with cognitive function and the number of prescribed drugs. Conclusion: Patients' ability to open and remove tablets from common commercial packages/containers should be tested routinely during a stay in hospital. Management of medication should be taught and supervised within the first few days after discharge from hospital.

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").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.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.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.

The objective of the study was to compare compliance with and the hypocholesterolaemic effect of lovastatin given once daily as a morning or an evening dose. Twenty-four out-patients with familial hypercholesterolaemia were randomly assigned to receive placebo first, then lovastatin 20 mg, to be taken once daily for 4 weeks, either with the breakfast or evening meal, in a single-blind fashion. Drug compliance was assessed by pill counts and continuous electronic monitoring. Two compliance parameters were evaluated, consumption, defined as percentage of prescribed doses taken, and time compliance, the percentage of total dosing events recorded within defined intervals (6.00-10.00 h, and 17.00-21.00 h), for the morning and evening regimes. Both regimes satisfactorily reduced the total and LDL-cholesterol concentrations, and there was no significant difference in the extent of the reductions. Pill counts overestimated compliance, as revealed by the monitoring method. The times of actual consumption of doses by the patients often differed from that prescribed, predominantly in patients who were told to take the evening dose. Partial time compliance may have confounded the efficacy of the drugs. Electronic compliance monitoring appears to be particularly useful in chronopharmacological studies.

To integrate palliative care patients into an acute geriatric ward requires extensive and continuous education and preparation of all participating professionals. It can be a lengthy process to integrate palliative care concepts despite cooperation of the hospital administration. The group of patients to be integrated differs from the patients of regular geriatric wards because of a higher percentage of relatively young oncologic patients and they differ from a regular palliative ward because about 50% are non-oncologic patients, while the average age is much higher than in normal palliative care. It is possible to integrate specialized palliative care into a regular geriatric ward. Patients admitted without palliative intention will benefit the most from ward-integrated palliative care if the treatment aim turns this way. Ward-integrated palliative care can be an integral part of treating geriatric patients in addition to acute geriatric medicine, rehabilitation, and prevention. It can also provide caretakers and patients with the benefits from continuity of treatment and care.

The effects of low fat diet and intensive physical exercise were examined in a randomized prospective study in patients with angiographically documented coronary heart disease. In addition to supervised regular physical exercise, patients of the intervention group (n = 18) were subjected to intensive dietary counselling with the aim of a low fat, low cholesterol diet to be maintained for at least 12 months. The control group (n = 27) received relevant advise only and usual care by private physicians. In the intervention group there was significant lowering of plasma triglycerides (202 +/- 82/141 +/- 74 mg/dl) and body weight (78.2 +/- 9.5/73.7 +/- 10.4 kg) while total and LDL cholesterol did not change significantly. There was a tendency for a rise of HDL-cholesterol (35.6 +/- 9.0/40.4 +/- 14.8 mg/dl, p = 0.07). According to 24-hour diet protocols there was a significant lowering of energy intake (2.298 +/- 697/1.602 +/- 758 kcal/day), of fat intake (111.7 +/- 44.4/52.0 +/- 23.9 g/day) and of intake of dietary cholesterol (402.8 +/- 186/161.3 +/- 100.3 mg/day) as well as of saturated fatty acids (42.5 +/- 20.4/14.3 +/- 8.1 g/day). Fatty acid composition of adipose tissue was not correlated with the patients' 24-hour dietary protocols. In the control group there were no changes of plasma lipids, body weight or diet composition according to 24-hour protocols after 1 year compared to data at the beginning of the study. There was, however, a marked correlation of adipose tissue composition and dietary information given by the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

In many acute or chronic vestibular diseases in old age, the risk of falling is increased. A fear of falling often develops together with further limitations to physical activity and subsequent physical and psychological consequences. Falls represent a substantial health-related risk factor. A regular balance, walking and muscle training is an effective prophylaxis. Components of the treatment of vestibular diseases in old age are counselling and encouragement (psychotherapy), treatment of the specific organic disease, specific vestibular rehabilitation and a symptomatic medication therapy. Vertigo in old age is a multifactorial process. The differential diagnosis of disorders of the equilibrium function in old age represents a challenge which can only be overcome by interdisciplinary cooperation.

Disorders of the equilibrium function in the elderly will increase in the coming years due to demographic changes in Germany. In addition to a reduction in the quality of life of affected patients, the risk of suffering from a fall increases with age. At the morphological level age-specific changes of the peripheral vestibular structures, somatosensory pathways and vision can be found, such as degenerative alterations, reduced number of cells and receptors and an accumulation of lipofuscin. Disorders of the equilibrium function in old age are individual-specific, complex procedures which develop from age-related physiological, degenerative alterations in the components of the sensomotor system which maintain equilibrium and can come into being together with vestibular and non-vestibular accompanying diseases as well as psychological factors.

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.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.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).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.

The observation scale PAINAD (pain assessment in advanced dementia) is composed of five behavioral categories: breathing, vocalization, facial expression, body language, and consolability. The present study investigates the construct validity of the German version.We conducted a prospective one-dimensional observation study with repeated measurements (t(1)=pretreatment, t(2)=2 h posttreatment, t(3)=24 h posttreatment). The sample consisted of 12 verbally noncommunicative demented inpatients with severe comorbidity treated in three geriatric clinics. Their age was M=84.3 years (SD=4.4) on the average. Ten of them were female. Inclusion criteria were pain-related physical illness and observed pain behavior. Every patient was treated with analgesics after t(1). After t(2) the medication was discontinued in five patients until t(3). Nurses documented the PAINAD scores after an observation period of 2 min during routine care.Pain behavior at t(2) diminished considerably displaying a large effect size. Scores continued to be low at t(3) only in the sample with continued medication. Scores in the other part of the sample returned to initial values.The data demonstrate that pain medication strongly impacts the pain behavior of demented patients. The outcome supports the assumption that PAINAD really measures pain.

Objective: To investigate the correlation between objective and subjective evaluation of patients with total hip replacement. Design: Prospective preliminary trial comparing the Western Ontario and McMaster University questionnaire (WOMAC) and gait analysis preoperatively and three months postoperatively. Setting: A German academic orthopaedic centre specializing in total hip replacement surgery. Subjects: Seventeen patients (median age 70 years) with hip osteoarthritis. Intervention: All patients had had a primary unilateral total hip replacement. Main measures: WOMAC questionnaire to assess self-perceived health status and gait analysis to determine objective gait parameters. Results: Performance of walking as well as subjective judgement of health status improved following surgery (gait speed P = 0.0222; stride length P = 0.038; stance phase ratio P = 0.0466; WOMAC P < 0.0001). However, the correlation between gait parameters and WOMAC was poor ( r = -0.27 or less). Correlation between changes of walking parameters and WOMAC was bad to good ( r = 0.01 to r = -0.72). Conclusion: The WOMAC questionnaire might not reflect walking performance. The addition of gait analysis is recommended to gain objective information about the quality of gait.

A primary goal of pain treatment in geriatric patients is the maintenance of physical and mental functions. This is a precondition for activity and participation. In patients with chronic pain, multidisciplinary treatment, without excluding invasive procedures, is the most effective approach. The medication ladder, initially suggested by the WHO for cancer pain, provides a guideline for pharmacological treatment. Due to age-dependent alterations in the kinetics and dynamics of pharmaceuticals, the titration of the medication follows the rule "start low-go slow". The same principle holds true for the maintenance or augmentation of physical activity in order to escape from the activity-deconditioning cycle. Training should be based on learning theories, include pain management strategies, and incorporate psychological approaches to facilitate the active participation of the patient in the treatment program. In hospitals and nursing homes, nurses play an important role in defining the need for pain treatment and in supervising the patient in the treatment process. Despite these endeavours, a significant number of patients remain whose pain cannot be controlled sufficiently. Euthanasia on demand for a patient with untreatable pain is not admitted in Germany.

Surgical treatment, discharge planning and rehabilitation procedures are rarely based upon defined assessment procedures. It might therefore be useful to develop simple and reliable screening tools to identify patients for early discharge, intensified rehabilitation and limited treatment.234 patients were initially contacted. From these 217 gave informed consent. The reported study included the 134 home dwelling elderly. All patients could be contacted or died after six month. Thus,data from more than 90% could be used for the analysis. The six month mortality was 10%. A population based cohort of elderly patients referred to five local hospitals was tested. Mortality, institutionalisation and mobility were defined as major outcome criteria. Only information that was available during the first week of treatment was used in the model. Predictors expressed as odd ratios (OR) were calculated using logistic regression with variable selection.The most important predictors for institutionalisation were age, inability to eat without assistance, postoperative night time confusion, stroke history, cognitive deficit and fear of falling. Outdoor mobility was strongly associated to the preoperative ADL performance measured as the Barthel-Index, history of malignancy and fear of falling. Six month mortality was associated with male sex, the Barthel-Index and fear of falling.It seems feasible to improve postoperative resource allocation by predictor led stratification. This need to be tested in intervention trials under the specific condition of the German health care system.

For a dietary anti-aging concept that "gives life to years and adds years to life" we recommend a low-fat, carbohydrate and fiber-rich diet containing plenty of fruits and vegetables and moderate amounts of protein (in particular of vegetable origin). Prolonging the fasting state by cancelling dinner is also of benefit. Five servings of fruits and vegetables (preferentially red, yellow and green) daily and whole-grain products provide sufficient amounts of vitamins C and E and the provitamin A beta-carotene, as well as secondary phytochemicals. Also to be recommended are low-fat dairy products, fish once or twice a week, little meat and eggs, and a maximum of 4-8 fl oz (1/8 to 1/4 liter) of red wine per day.

The main objective of the study was to examine the prevalence of problems and resources of an unselected cohort of nursing home residents. The sample includes residents (n=769) of an urban area in Southern Germany. The assessment definitions were used according to the Minimum Data Set of the Resident Assessment Instruments (Version 2.0).The mean age was 84.2 years, 608 of the residents were female. Dementia (446) and stroke (185) were the most common main diagnosis. Syndrome prevalences are reported for depressive symptoms (323), mobility impairments (608), urinary incontinence (461), decubitus (54), use of restraints (54), disruptive behavior (185), psychopharmacy (377), severe visual impairment (123) and severe hearing impairment (123).

In old age, assessment of pain often is hampered by sensory and cognitive deficits that do not allow the patients to fill in standardized questionnaires without help from significant others. Therefore, as an alternative, we developed a structured pain interview, and examined its properties and acceptance in a sample of geriatric patients with pain.The interview covers site of pain, intensity of pain, its duration and persistency, pain related disability and, finally, emotional and cognitive variables. In addition, the interviewer addresses significant others to get information about medication, previous treatment, and residence, and administers the Mini-Mental-State-Examination (MMSE). The analysis includes 128 patients of pain centers older than 74 years, of whom 80% are female.Forty percent of the subjects score below the critical MMSE valueor =23 indicative of cognitive impairment. These patients are responsible for 36 out of a total of 39 missing values. A significant increase of missing values is observed in patients with a MMSE score below 10. Cognitive impairment goes along with greater functional and social disability. On the other hand, cognitive impairment is unrelated to localization, intensity, and duration of pain. The memory item of the MMSE can be used as a screening tool for cognitive impairment. Patients, who are unable to recall any of the three objects, comprise 80% of the total of missing values and demonstrate a low MMSE score.As long as geriatric patients are able to communicate verbally, they are most likely to profit from the structured pain interview in spite of existing cognitive impairment. A MMSE score10 indicates that the interpretation of the data obtained may be difficult, especially due to a high frequency of missing values.

In comparison with younger patients, the elderly are at an appreciably higher risk of contracting an infectious disease. Such infections can be prevented or ameliorated by appropriate vaccination, in particular in the case of pneumococcal pneumonia, influenza and tetanus. Older individuals may have an attenuated response to immunization, presumably because of inadequate thymus gland function and the weakening of cell-mediated immunity and, secondarily, of the humoral immune response to antigens. Studies have shown that the immunization rate among the elderly in Germany is inadequate; this applies in particular to the high-risk population living in nursing homes. Campaigns aimed at increasing awareness of the need for immunization are therefore urgently required.

Most geriatric assessment instruments have been developed in the English language. Translated versions might differ in their psychometric properties. We analyzed the test-retest reliability and internal consistency of a German instrument for multidimensional geriatric assessment that was based on a newly developed English version. A group of 100 over 75-year-old community-dwelling persons (mean age 83.0 years, 81% women) in Hamburg (n = 26) and Ulm (n = 51), Germany, and Berne (n = 23), Switzerland was interviewed twice by the same trained interviewers with a one week interval. We administered questions on general health, chronic disorders, basic and instrumental activities of daily living, urinary incontinence, nutrition, falls, pain, the social support/network and preventive care measures. In addition, the Functional Status Questionnaire, the Physical Activity Scale for the Elderly, the Geriatric Oral Health Assessment Index, the Visual Function Questionnaire, the Hearing Handicap Inventory for the Elderly and the Geriatric Depression Scale were administered. Cohen's kappa was good to excellent (0.64or = kappaor = 0.89) with only three exceptions (pain questions, kappa = 0.53; questions on preventive care services, kappa = 0.51; and one of the questions on recent falls, kappa = 0.44). Cronbach alpha (internal consistency) was good to excellent for all domains (0.76or = alphaor = 0.95). The study results confirm good test-retest reliability of the German version of this multidimensional geriatric assessment instrument. Adapted versions of this instrument can be used for different purposes, e.g., preventive home visits, outpatient geriatric assessments or epidemiological studies in older persons.

Comprehensive geriatric assessment was developed in the Anglo-American countries as a diagnostic process to better understand the effects of diseases and interactions of multiple chronic conditions. To standardize the use of assessment instruments, a working group of the two German geriatric societies has elaborated recommendations. As the first step, an expanded version of the screening according to Lachs should be used, followed by performing the Barthel-ADL, the Mini-Mental State Examination, the Geriatric Depression Scale, the 'Timed Up and Go' and the (Semi-) Tandem Stance. The expanded version of the screening of Lachs is helpful for targeting patients and for placement; the others are not useful for that purpose. No instrument satisfactorily fulfills all test criteria, which include validity, reliability, sensitivity, practicability and repeatability, and, in part, these dimensions are not investigated at all. All test instruments are diagnostic tools for functional status and capabilities but do not give information about resource needs. No instrument covers the new concept of ICIDH completely.

Some 25-50% of all elderly persons living at home suffer from chronic pain. Among nursing home residents, the figures are appreciably higher, ranging between 45% and 80%. The major causes of pain in old age are degenerative joint disease, lower back pain, cancer, osteoporosis and herpes zoster, polymyalgia rheumatica, and arterial occlusive disease. In many cases, chronic pain goes undiagnosed and is not properly treated. When a correct diagnosis is established, however, it is almost always possible to achieve adequate pain relief by a combination of non-drug treatment and analgesics, and thus to improve the patient's quality of life.

Nursing homes are important, but often neglected, facilities for the care of frail older people. The demand for nursing home capacity in Germany will continue to increase over the next decade despite improvements in infrastructure of home care and day care centers. The leading medical reason for this is the growing number of elderly persons suffering from neurodegenerative diseases, depression, and stroke. Currently, more than 650,000 residents are in various forms of institutionalized care in Germany. To date, the medical profession has shown little interest in establishing an efficient medical care system for such patients, nor are care-providing physicians required to undergo special training in Germany. The article describes current practice and future principles of geriatric treatment.

In Germany the implementation of specialized wards for the care of stroke patients is proposed. However, which type of organized inpatient stroke unit care is most effective and which group of patients will benefit most remains unclear.Based on the analyses of the Stroke Unit Trialists' Collaboration this paper reports results of randomized and quasi-randomized trials that compared organized inpatient (stroke unit) care with contemporary conventional care. The primary analyses examined death, dependency and institutionalization. Secondary outcome measures included patient quality of life, patient and carer satisfaction and length of stay in hospital and/or institution.The analysis of twenty trails with 3864 patients showed a reduction in the rate of deaths in the stroke unit group as compared with the control group (OR 0.83, 95% CI 0.71-0.97). The odds of death or institutionalized care were lower (OR 0.76, 95% CI 0.65-0.90) as were death or dependency (OR 0.75, 95% CI 0.65-0.87). The results were independent of patient age, sex, stroke severity, and type of stroke unit organization.Organized care in stroke units resulted in benefits for stroke patients with regard to survival, independence, and probability of living at home. However, these results refer exclusively to Anglo-American and Scandinavian trials. German stroke unit services are organized in a different way. No data about the effectiveness of the German model is yet available.

Preventive home visits with multidimensional geriatric assessment have been shown to delay or prevent the onset of disability and reduce nursing home admissions in older people. The purpose of the present study was to develop and test a multidimensional instrument for in-home preventive assessments in older persons. In developing the instrument, we conducted a systematic literature review of risk factors for functional status decline and of appropriate instruments for measuring these risk factors. Based on an Expert Panel using a modified Delphi process [1] the risk factor domains for functional status decline were chosen, [2] the instruments for evaluating each of the included risk factor domains were selected, and [3] the individual instruments were combined into one comprehensive assessment instrument. A German language version of the original English version of the instrument was developed based on translation, backtranslation, and cultural adaptation. The feasibility of use of the new instrument was evaluated in a field test in 150 people aged 75 years and older in Hamburg, Ulm, Germany, and Bern, Switzerland. The instrument was well accepted by the older persons. The prevalence of risk factors for functional status decline in these populations (e.g., physical inactivity, urinary incontinence, vision impairment) was high. There was also a high prevalence of underuse of preventive care measures (e.g., no pneumococcal vaccination in over 95 percent of persons). These preliminary results support the possible usefulness of this instrument for conducting preventive home visits or for epidemiological purposes (e.g., prevention surveillance). In a next phase, the test-retest reliability of the instrument, and the feasibility and reliability of self-administration as compared to interviewer administration will be described in a separate paper.

There is a lack of epidemiological data on falls and fall-related injuries for the aged population in Germany. The purpose of the article is to present the available data focusing on the incidence of the fracture types that carry the highest risk for mortality, hospitalization and persisting disabilities.The paper reports on a 10% representative sample that was drawn by the Federal Bureau of Statistics. A medline search for 1980-1998 was performed to identify relevant articles. The OECD database was used for mortality rates after injurious falls. If no sufficient data were published for Germany, incidence rates of demographic comparable European regions are reported.The number of fractures of the lower extremity (ICD 820-829) followed by hospitalization was 139,000 in 1996 for elderly (65+ years). Fractures of the upper extremities (ICD 810-819) requiring hospitalisation were reported for 65,000 persons aged 65+ years and head trauma (ICD 850-851) followed by hospitalization in this age group for 29,000 persons. There remains an information gap on the incidence of falls and fall-related sequelae without hospitalization in Germany.Facing, the demographic transgression the prevention of falls and fall-related injuries gains a high priority. Operative management and rehabilitation procedures for elderly trauma patients should be further evaluated and improved.

to examine mortality, mobility, pain, institutionalization rates six month after hip fractures.observational study, non-selected consecutive patients, time-set protocol.urban area (population n = 116,5000), five hospitals.hip fracture patients (n = 214), age 65 + years (mean 82.4 years).age, gender, prefracture status, operative procedures, complications, comorbidity, cognition (MMSE), depression (GDS), fear of falling, ADL (Barthel) and mobility and pain status (SAHFE protocol).the incidence for this age group was 636.9/100,000, 31.8% were institutionalized elderly. 84% of the patients were female. Pre-existing comorbidity showed a high prevalence of neurodegenerative (cognitive deficits 53. 6%, Parkinson's disease/syndrome 11.2%) and cerebrovascular diseases (16.8%). Six month postfracture, the mortality was 17.6%. From those surviving 76.2% did walk indoors, 58.5% did also walk outdoors. Independent to dress were 54.6%. Severe pain was reported by 10.2%, whereas 36.9% described no pain. The institutionalization rate at six month was 19.0%.the study showed considerable mortality, a significant loss in function and social disintegration. Considerable differences were observed for subgroups of patients. Future treatment should focus on risk stratification and include postdischarge training programs. Moreover, preventive strategies should be implemented for high risk groups, such as ambulating patients with a history of stroke. Parkinson's disease and syndrome, dementia and nursing home residents.

The purpose of the study was to identify associations between drug prescriptions and the risk of falls in community-dwelling frail elderly people. 360 frail elderly patients underwent a comprehensive geriatric assessment during hospital stay. After discharge, the home falls were recorded by a questionnaire during the follow-up year and a home visit was carried out at the end of the year. Of 279 final patients with complete data, 141 subjects (50.5%) fell once; 62 subjects (22.2%) had a history of two or more falls during the follow-up period. Compared with subjects who did not fall or fell at the most once, those subjects with two or more falls showed a significantly higher prescription of tranquillizers/hypnotics, neuroleptics, diuretics, nitrates, and five or more different drugs. In multivariate analysis the prescription of tranquillizers/hypnotics with an adjusted odds ratio of 2.02 (95 percent confidence interval, 1.14 to 3.68) and the prescription of five or more different drugs with an adjusted odds ratio of 2.25 (95 percent confidence interval, 1.03 to 4.49) were found to be independent risk factors for multiple falls. In this prospective study in community-dwelling frail, elderly people the prescription of tranquillizers/hypnotics and five or more different medications could be identified as independent risk factors for multiple falls.

To assess the situation of geriatric research and education at German universities, a questionnaire was sent out to all medical faculties (n = 37). The response rate was 91.9% (n = 34). There are five universities with a geriatric chair (14.7%), one with a department of geriatric medicine within internal medicine, and two departments of geriatric psychiatry. At 15 universities geriatric research is established (44.1%), but only 12 universities report that geriatric contents are implemented in the teaching of medical students. The comparison of universities with and without geriatric chairs and departments showed big differences. Whereas all universities with geriatric chairs or departments conduct geriatric research and offer education in geriatric medicine, the others failed to do so. Only 26.9% (n = 7) have geriatric research and 15.4% (n = 4) offer medical teaching in geriatrics. There is a strong link between geriatric chairs, research, and pregraduate teaching. Geriatric medicine is established only at few universities. To improve the overall situation of geriatrics in Germany the implementation of further geriatric chairs and departments at universities seems to be necessary.

The article presents the design of an open controlled, non-randomized population based intervention trial in institutionalized elderly that will be performed in Ulm/Germany starting in 1998. The multimodal intervention includes education, counseling, training, and hip protectors as well as information on potential environmental modifications in nursing homes. Two historical and one geographical control group will be formed. All institutionalized elderly will be assessed by means of the Minimum Data Set of the Resident Assessment Instrument. The intervention will last 12 months. The main objective is to test a model for cost-effective reduction of proximal femoral fractures in institutionalized elderly and to demonstrate its effectiveness.

Pain is extremely common among older people but often inadequately treated. Chronic pain and its management have major implications for quality of life and quality of care, especially for terminal ill patients and residents of long-term-care facilities. Many physicians lack information about pain assessment and may have an inaccurate knowledge base about pharmacological agents and non-pharmacological approaches used in pain control. Although fundamental data on the pathophysiology and management of chronic pain is still lacking there is some information to provide a framework for rational nosology and therapeutic strategy. Some guidelines may help to improve pain assessment and management in elderly people and may help to enhance physicians' awareness about that problem.

The purpose of this prospective study was to measure patients’ ability to open a purse, take out money, and count it, in order to identify persons in need of increased health care. The study population consisted of 183 patients (mean age 78.9; range: 66-95) in two settings: 78 consecutively admitted geriatric hospital patients who could return home, and 105 community-dwelling patients aged 70 years or older. None was completely dependent on others, nor severely demented. Time for task performance was measured. Further assessment included the Mini-mental State Examination (MMSE), Barthel index of ADL, instrumental activities of daily living (IADL), socioeconomic status, grip strength, Williams board test, and medication profile. The Timed Test of Money Counting (TTMC) was reliable (interrater and intrarater), and showed construct and concurrent validity with other measures of physical function. There was a strong correlation (p

The transition team has its place in pre- and postdischarge nursing and therapeutic care, on the basis of a geriatric assessment. Core members of the team are, in the sequence of the scheduled performance in-hospital, nurse, occupational therapist, physiotherapist and social worker, supplemented by a team physician. Two-thirds of all treatments were in the hospital, one-third in an outpatient setting up to 4 weeks after discharge. Cooperation with outpatient services has been good.

In this ongoing randomized controlled trial the effectiveness of an interdisciplinary team implementing hospital-based comprehensive geriatric assessment (CGA) and home intervention is being studied. All patients admitted from home showing functional decline with impairment of any basic activity of daily living are randomly assigned to one of the following courses of treatment: CGA with in-hospital and post discharge management by a home intervention team (HIT), where necessary (group 1): CGA with recommendations and usual care at home (group 2); or usual hospital and home care (group 3). The HIT consists of 3 nurses, 1 geriatrician, 1 physiotherapist, 1 occupational therapist, and 1 social worker. 540 patients will be recruited for the trial, which will assess the effects of GEM-HIT on the following outcomes: health status, functional status, survival, hospital readmission, nursing home placement and costs. The purpose of the GEM-HIT trial is to answer many of the current questions concerning treatment and health care delivery for frail older persons under the specific conditions found in Germany. The large sample size and the broad range of diagnoses included in the study will allow the evaluation of effects of GEM-HIT for subgroups and may help to identify the most effective assessment tools for use within our particular context.

The value of a diagnostic home visit as part of hospital-based geriatric assessment was examined in a prospective study. 141 subjects admitted from home to the geriatric hospital and showing functional decline with risk of nursing home placement underwent a comprehensive geriatric assessment and a diagnostic home visit. In 19.1% of the patients, the diagnostic visit resulted in a change of time, and in 14.9% in a change of location of discharge. Up to seven problems were newly discovered (mean 2.1). To maintain independence up to six technical aids were prescribed (mean 2.3). The most common recommendations were related to safety (59.2% of all cases). In 89.3% the diagnostic home visit was judged necessary by the home intervention team. A follow-up visit after 3 months revealed that about 80% of all recommendations were implemented and approximately the same amount of technical aids were still used. The diagnostic home visit allows individual prescription of technical aids, when necessary. It contributes meaningful information to the geriatric assessment process and helps to achieve successful in-hospital therapy and discharge planning. It can be recommended especially for elderly patients at risk for losing their independence.

To enhance physicians' awareness of nutritional problems in the elderly, a nutritional risk assessment scale was developed and validated. 126 patients (mean age 82.0 +/- 6.7, range 65-96 years) admitted from home to a geriatric hospital were enrolled in the study. After informed consent was obtained, they underwent a comprehensive geriatric assessment of physical, emotional, and cognitive functions, overall functional capacity, and social situation. The nutritional status was assessed by the nutritional risk assessment scale. This scale consists of items relating to gastrointestinal disorders, chronic diseases with pain, immobility, alterations in body weight, appetite, difficulties in eating, cognitive or emotional problems, medication, smoking and drinking habits, and social situation. The maximum score which indicates a high risk is 12. The scores from the nutritional risk assessment scale were compared with a physician's clinical judgement (patients being graded as "obese', "well-nourished', "undernourished') as the "gold standard' and with body mass index, other anthropometric findings, and serum albumin and prealbumin levels. The nutritional risk assessment scale was reliable (inter- and intrarater) and showed construct and concurrent validity. There was a significant correlation with clinical judgement (p0.01) and other parameters of nutritional status (p0.05). The scores of undernourished patients (n = 37; 5.35 +/- 1.60, range 3-8) were significantly different (p0.05) from those who were classified as well nourished (n = 63; 2.66 +/- 1.59, range 0-7) or obese (n = 26; 2.73 +/- 1.76, range 0-7). When implemented as part of a comprehensive geriatric assessment, this questionnaire can be completed within 5-10 min. The nutritional risk assessment scale is simple and reliable and helps in the identification of elderly patients at risk of poor nutrition.

Psychiatric diseases are very common among elderly people. Depressions rank before dementias in this age group. 2-2.5 million people aged over 65 years are suffering from symptoms of depression in Germany. Patients with Mayor Depression Disease (MDD) have a poor prognosis. MDD should therefore be recognized and treated in community dwelling elderly, in nursing homes and in hospitals. Underdiagnosis of MDD is well documented in the medical literature. Only a quarter of patients with a MDD are detected. By a short screening test for depression such as the Geriatric Depression Scale (GDS) depressed patients can be identified. With a sensitivity and specificity of about 70%. The time needed to perform the short form of the GDS is only 5-7 min. The GDS is an important part of many assessment programs in England and USA. It is also recommended in Germany by the "Geriatric Assessment" working group.

This work presents preliminary recommendations for a three-step geriatric assessment approach developed by a newly created working group consisting of members from nine geriatric departments in Germany and Switzerland. The recommendations were based on a literature review, expert consultation, and a consensus meeting. As part of this effort, instruments and guidelines for selected geriatric assessment instruments were translated and will be tested in German language. Further research is planned for refining the recommended method. Currently, these recommendations might help to stimulate the spread of geriatric assessment method in German-speaking areas and facilitate joint research projects among geriatric institutions.

To evaluate functional disabilities in elderly patients, geriatric assessment was performed in one general practice. Excluded from the study were patients with severe dementia and dependence. 178 patients were asked to participate and 144 accepted (mean age 78.7 +/- 5.8 years; number of diagnoses 5.2 +/- 2.6; f = 95, m = 49). Mini-mental-status examination showed moderately but significantly lower (p0.05) cognitive capacity in the age groups of 80-84 years (n = 37, 24.56 +/- 4.90 points) and of 85 years and older (n = 30, 25.14 +/- 3.11 points), but not in the group of 75-79 years (n = 46, 26.70 +/- 3.90 points) compared to the group of 70-74 years (n = 31, 27.65 +/- 2.59 points). Neither the Geriatric Depression Scale nor the Barthel-Index (activities of daily living) showed significant differences between the age groups. The score of the instrumental activities of daily living (Lawton Index) was significantly lower (p0.05) in the age group 85 years and older (4.1 +/- 2.5 points) compared to the age group of 70-74 years (6.1 +/- 2.4 points). Grip strength was significantly reduced (p0.01) in the age group 85 years and older as well as motility and balance scores (Tinetti test; p0.05) compared to the group of 70-74 years (43.21 +/- 16.27 kp and 64.87 +/- 19.81 kp, resp., 19.3 +/- 6.6 and 23.1 +/- 5.9 points). No correlation was found between the results of functional assessment and number of contacts with the general practitioner in the past year, number of prescribed drugs and number of diagnoses except for the depression test. There was a significant correlation between test score, number of contacts, and number of diagnoses (p0.05). Functional assessment resulted in new diagnoses of urinary incontinence in 7 patients and of mobility disorders in 17 patients. Cognitive impairment was suspected in 14 patients, depression in 2 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

To evaluate social aspects of elderly patients which are important for diagnosis and therapy within geriatric assessment, a questionnaire was developed and validated. Raters showed a high degree of agreement on the scale, which contains social contacts and support, activities, economic situation, and housing conditions (0.92-0.97; p0.05). Compared to the interrater reliability the test-retest reliability was somewhat lower (0.75), but also significant at the 5% level. The internal consistency showed high values between 0.72-0.89. In order to evaluate the validity of the screening test the answers of the patients were compared with the assessment of the therapeutic team. The team had information from a home visit, patients spouse, relatives, neighbors, community nurses and/or general practitioners. There was a significant relationship (p0.01) between therapeutic assessment and the scale (r = 0.51). Sensitivity, specificity, and total efficiency also attained sufficiently high values at a cut-off of 16/17 for the complete scale (max. 25 points). The test is easily and quickly performed; its acceptance is high. Social data relevant for treatment and discharge planning can thus be obtained and patients can be identified, for whom a home visit seems to be useful.

The causes of early rehospitalization (within 3 weeks) of very elderly patients, its possible avoidance and appropriate preventive measures were analysed retrospectively in patients of a geriatric hospital. Included were all those patients who had been admitted to the hospital from their home several (mean: five) times between 1987 and 1990 (48 women, 19 men; mean age 81.3 +/- 7.2 years--a total of 331 re-admissions). The most frequent diagnoses were heart failure (38.8%), acute cerebrovascular accident or its sequelae (31.3%), dementia (23.9%), fall or its sequelae (22.3%) and diabetes (20.9%). Of the 331 re-admissions 87 (26.3%) occurred during the first 3 weeks after discharge. The most important reasons of this early re-admissions were inadequate home care (41.4%), undesirable drug effects and non-compliance (25.3%), as well as rapid progression of the basic disease (14.9%). In the judgement of the hospital team more than 40% of the early re-admissions were avoidable, among those re-admitted because of inadequate home care and those in connection with drug intake even more than half. Early hospitalization is frequently avoidable, if individual geriatric assessment is undertaken and discharge carefully planned.

The competent handling of money is an essential basis for living independently. Seventy-eight consecutively admitted patients to a geriatric hospital underwent the Timed Test of Money Counting (TTMC) which measures patients' ability to open a purse, take out all the money and count it. Further assessment included Mini-Mental State Examination (MMSE), Barthel Index of ADL, Self-maintaining and Instrumental Activities of Daily Living (IADL), grip strength and Williams' Board Test. The TTMC was reliable (inter-rater and intra-rater) and showed construct and concurrent validity with other measures of physical function. Unlike many other physical performance tests the TTMC is quickly performed and requires no special equipment or training.