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Background: Neurodegenerative disorders, including Alzheimer's disease (AD), have been linked to alterations in tryptophan (TRP) metabolism. However, no studies to date have systematically explored changes in the TRP pathway at both transcriptional and epigenetic levels. This study aimed to investigate transcriptomic, DNA methylomic (5mC) and hydroxymethylomic (5hmC) changes within genes involved in the TRP and nicotinamide adenine dinucleotide (NAD) pathways in AD, using three independent cohorts., Methods: DNA derived from post-mortem middle temporal gyrus (MTG) tissue from AD patients (n = 45) and age-matched controls (n = 35) was analyzed, along with DNA derived from blood samples from two independent cohorts: the German Study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe) cohort (n = 96) and the Dutch BioBank Alzheimer Center Limburg (BBACL) cohort (n = 262). Molecular profiling, including assessing mRNA expression and DNA (hydroxy)methylation levels, was conducted using HumanHT-12 v4 Expression BeadChip and HM 450 K BeadChip arrays, respectively. Functional interactions between genes and identification of common phenotype-specific positive and negative elementary circuits were conducted using computational modeling, i.e. gene regulatory network (GRN) and network perturbational analysis. DNA methylation of IDO2 (cg11251498) was analyzed using pyrosequencing., Results: Twelve TRP- and twenty NAD-associated genes were found to be differentially expressed in the MTG of AD patients. Gene sets associated in the kynurenine pathway, the most common TRP pathway, and NAD pathway, showed enrichment at the mRNA expression level. Downstream analyses integrating data on gene expression, DNA (hydroxy)methylation, and AD pathology, as well as GRN and network perturbation analyses, identified IDO2, an immune regulatory gene, as a key candidate in AD. Notably, one CpG site in IDO2 (cg11251498) exhibited significant methylation differences between AD converters and non-converters in the AgeCoDe cohort., Conclusion: These findings reveal substantial transcriptional and epigenetic alterations in TRP- and NAD-pathway-associated genes in AD, highlighting IDO2 as a key candidate gene for further investigation. These genes and their encoded proteins hold potential as novel biomarkers and therapeutic targets for AD., Competing Interests: Declarations. Ethics approval and consent to participate: Donors of the BBDP signed an Institutional Review Board-approved informed consent form, including specific consent to the use of donated tissue for future research [16, 17]. The AgeCoDe study protocol was approved by the local ethics committees at the University of Bonn (Bonn, Germany), the University of Hamburg (Hamburg, Germany), the University of Duesseldorf (Duesseldorf, Germany), the University of Heidelberg/Mannheim (Mannheim, Germany), the University of Leipzig (Leipzig, Germany), and the Technical University of Munich (Munich, Germany). Lastly, the BBACL study protocol was approved by local ethics committees (METC 15-4-100) at the MUMC+ (Maastricht, the Netherlands). All participants gave their written informed consent. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Introduction: The prevalence of mild cognitive impairment (MCI) and dementia is increasing as the oldest old population grows, requiring a nuanced understanding of their care needs. Few studies have examined need profiles of oldest old patients with MCI or dementia. Therefore, this study aimed to identify patients' need profiles., Methods: The data analysis included cross-sectional baseline data from N = 716 primary care patients without cognitive impairment (n = 575), with MCI (n = 97), and with dementia (n = 44) aged 85+ years from the multicenter cohort AgeQualiDe study "needs, health service use, costs and health-related quality of life in a large sample of oldest old primary care patients [85+]". Patients' needs were assessed using the Camberwell Assessment of Needs for the Elderly (CANE), and latent class analysis identified need profiles. Multinomial logistic regression analyzed the association of MCI and dementia with need profiles, adjusting for sociodemographic factors, social network (Lubben Social Network Scale [LSNS-6]), and frailty (Canadian Study of Health and Aging-Clinical Frailty Scale [CSHA-CFS])., Results: Results indicated three profiles: "no needs," "met physical and environmental needs," and "unmet physical and environmental needs." MCI was associated with the met and unmet physical and environmental needs profiles; dementia was associated with the unmet physical and environmental needs profile. Patients without MCI or dementia had larger social networks (LSNS-6). Frailty was associated with dementia., Conclusions: Integrated care should address the needs of the oldest old and support social networks for people with MCI or dementia. Assessing frailty can help clinicians to identify the most vulnerable patients and develop beneficial interventions for cognitive disorders., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Purpose: The present study aimed to investigate age-group-specific incidence rates and risk factors for depressive symptoms in the highest age groups., Methods: Data were derived from a prospective multicenter cohort study conducted in primary care - the AgeCoDe/AgeQualiDe study. In total, 2,436 patients 75 years and older were followed from baseline to ninth follow-up. To assess depressive symptoms, the short version of the Geriatric Depression Scale (GDS-15, cutoff score 6) was used. Age-specific competing risk regressions were performed to analyze risk factors for incident depressive symptoms in different age groups (75 to 79, 80 to 84, 85+ years), taking into account the accumulated mortality., Results: The age-specific incidence rate of depression was 33 (95% CI 29-38), 46 (95% CI 40-52) and 63 (95% CI 45-87) per 1,000 person years for the initial age groups 75 to 79, 80 to 84 and 85+ years, respectively. In competing risk regression models, female sex, mobility as well as vision impairment, and subjective cognitive decline (SCD) were found to be risk factors for incident depression for age group 75 to 79, female sex, single/separated marital status, mobility as well as hearing impairment, and SCD for age group 80 to 84, and mobility impairment for age group 85+., Conclusion: Depressive symptoms in latest life are common and the incidence increases with increasing age. Modifiable and differing risk factors across the highest age groups open up the possibility of specifically tailored prevention concepts., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Luppa, Pabst, Löbner, Mallon, Brettschneider, Hajek, Heser, Kleineidam, Weyerer, Werle, Pentzek, Weeg, Mösch, Wiese, Oey, Wagner, Maier, Scherer, König and Riedel-Heller.)

Purpose: To examine the association of sociodemographic and health-related determinants with social isolation in relation to family and friends in the oldest-old., Methods: Database was the multi-center prospective AgeCoDe/AgeQualiDe cohort study assessed at follow-up wave 5 (N = 1148; mean age 86.6 years (SD 3.0); 67% female). Social isolation was assessed using the short form of the Lubben Social Network Scale (LSNS-6). The LSNS-6 contains two sets of items establishing psychometrically separable subscales for isolation from family and friends (ranges 0-15 points), with lower scores indicating higher isolation. Cross-sectional linear (OLS) regression analyses were used to examine multivariate associations of sociodemographic and health-related determinants with social isolation from family and friends., Results: Overall, n = 395 participants (34.6%) were considered socially isolated. On average, isolation was higher from friends (mean 6.0, SD 3.8) than from family (mean 8.0, SD 3.5). Regression results revealed that in relation to family, males were more socially isolated than females (β = - 0.68, 95% CI - 1.08, - 0.28). Concerning friends, increased age led to more isolation (β = - 0.12, 95% CI - 0.19, - 0.05) and functional activities of daily living to less isolation (β = 0.36, 95% CI 0.09, 0.64). Independent of the social context, depression severity was associated with more social isolation, whereas cognitive functioning was associated with less social isolation., Conclusions: Different determinants unequally affect social isolation in relation to family and friends. The context of the social network should be incorporated more strongly regarding the detection and prevention of social isolation to sustain mental and physical health., (© 2023. The Author(s).)

Background: Listing tools have been developed to improve medications in older patients, including the Fit fOR The Aged (FORTA) list, a clinically validated, positive-negative list of medication appropriateness. Here, we aim to validate MyFORTA, an automated tool for individualized application of the FORTA list., Methods: 331 participants of a multi-center cohort study (AgeCoDe) for whom the FORTA score (sum of overtreatment and undertreatment errors) had been determined manually (gold standard [GS]) were reassessed using the automated MyFORTA (MF) tool. This tool determines the score from ATC and ICD codes combined with clinical parameters., Results: The FORTA scores were 9.01 ± 2.91 (mean ± SD, MF) versus 6.02 ± 2.52 (GS) (p < 0.00001). Removing undertreatment errors for calcium/vitamin D (controversial guidelines) and influenza/pneumococcal vaccinations (no robust information in the database), the difference decreased: 7.5 ± 2.7 (MF) versus 5.98 ± 2.55 (GS) (p < 0.00001). The remaining difference was driven by, for example, missing nitro spray in coronary heart disease/acute coronary syndrome as the related information was rarely found in the database, but notoriously detected by MF. Three hundred and forty errors from those 100 patients with the largest score deviation accounted for 68% of excess errors by MF., Conclusion: MF was more sensitive to detect medication errors than GS, all frequent errors only detected by MF were plausible, and almost no adaptations of the MF algorithm seem indicated. This automated tool to check medication appropriateness according to the FORTA list is now validated and represents the first clinically directed algorithm in this context. It should ease the application of FORTA and help to implement the proven beneficial effects of FORTA on clinical endpoints., (© 2024. The Author(s).)

Background: Primary care research networks can generate important information in the setting where most patients are seen and treated. However, this requires a suitable IT infrastructure (ITI), which the North Rhine-Westphalian general practice research network is looking to implement., Objective: This mixed methods research study aims to evaluate (study 1) requirements for an ITI and (study 2) the usability of an IT solution already available on the market, the FallAkte Plus (FA+) system for the North Rhine-Westphalian general practice research network, which comprises 8 primary care university institutes in Germany's largest state., Methods: In study 1, a survey was conducted among researchers from the institutes to identify the requirements for a suitable ITI. The questionnaire consisted of standardized questions with open-ended responses. In study 2, a mixed method approach combining a think-aloud approach and a quantitative survey was used to evaluate the usability and acceptance of the FA+ system among 3 user groups: researchers, general practitioners, and practice assistants. Respondents were asked to assess the usability with the validated system usability scale and to test a short questionnaire on vaccination management through FA+., Results: In study 1, five of 8 institutes participated in the requirements survey. A total of 32 user requirements related primarily to study management were identified, including data entry, data storage, and user access management. In study 2, a total of 36 participants (24 researchers and 12 general practitioners or practice assistants) were surveyed in the mixed methods study of an already existing IT solution. The tutorial video and handouts explaining how to use the FA+ system were well received. Researchers, unlike practice personnel, were concerned about data security and data protection regarding the system's emergency feature, which enables access to all patient data. The median overall system usability scale rating was 60 (IQR 33.0-85.0), whereby practice personnel (median 82, IQR 58.0-94.0) assigned higher ratings than researchers (median 44, IQR 14.0-61.5). Users appreciated the option to integrate data from practices and other health care facilities. However, they voted against the use of the FA+ system due to a lack of support for various study formats., Conclusions: Usability assessments vary markedly by professional group and role. In its current stage of development, the FA+ system does not fully meet the requirements for a suitable ITI. Improvements in the user interface, performance, interoperability, security, and advanced features are necessary to make it more effective and user-friendly. Collaborating with end users and incorporating their feedback are crucial for the successful development of any practice network research ITI., (©Arezoo Bozorgmehr, Simon-Konstantin Thiem, Dorothea Wild, Melanie Reinsdorff, Horst Christian Vollmar, Annika Kappernagel, Kathrin Schloessler, Sabine Weissbach, Michael Pentzek, Dorothea Dehnen, Julia Drexler, Beate Sigrid Mueller, Larisa Pilic, Lion Lehmann, Susanne Loescher, Elena Darinka Hohmann, Friederike Frank, Gülay Ates, Susanne Kersten, Achim Mortsiefer, Benjamin Aretz, Birgitta Weltermann. Originally published in JMIR Formative Research (https://formative.jmir.org), 20.05.2024.)

Purpose: The present study aims to investigate the prospective effect of depressive symptoms on overall QoL in the oldest age group, taking into account its different facets., Methods: Data were derived from the multicenter prospective AgeCoDe/AgeQualiDe cohort study, including data from follow-up 7-9 and n = 580 individuals 85 years of age and older. Overall QoL and its facets were assessed using the WHOQOL-OLD instrument. The short form of the geriatric depression scale (GDS-15) was applied to assess depressive symptoms. Cognitively impaired individuals were excluded. Linear mixed-effects models were used to assess the effect of depressive symptoms on QoL., Results: Depressive symptoms were significantly associated with overall QoL and each of the different facets of WHOQOL-OLD, also after adjustment for time and sociodemographic characteristics such as age, gender, education, marital status, living situation, and cognitive status. Higher age and single as well as divorced marital status were also associated with a lower QoL., Conclusion: This work provides comprehensive longitudinal results on the relationship between depressive symptoms and QoL in the oldest age population. The results underscore the relevance of tailored and targeted care planning and the development of customized interventions., (© 2023. The Author(s).)

Introduction: After being diagnosed with dementia, patients need a medical professional to empathetically address their fears and get initial questions answered. This scoping review therefore addresses how patients newly diagnosed with dementia are cared for in the general practitioner (GP) setting and how the communication between different healthcare professionals and the GP is handled., Methods: The scoping review was conducted based on the PRISMA Extension for Scoping Reviews checklist. After developing a search algorithm, literature searches were performed in PubMed, Scopus, Web of Science, Cochrane Library, PsychInfo, GeroLit and Cinahl using defined search criteria, such as a focus on qualitative study designs. After the removal of duplicates, title/abstract and full text screening was carried out., Results: Final data extraction included 10 articles out of 12,633 records. Strategies regarding the post-acute care of newly diagnosed patients included providing clarity and comfort to the patients and giving support and information both pre- and post-diagnosis. Care efforts were focused on advanced care planning and deprescribing. Involving people with dementia and their caregivers in further care was seen as crucial to provide them with the support needed. GPs emphasised the importance of listening to concerns, as well as ensuring wishes are respected, and autonomy is maintained. All studies found communication between the GP setting and other healthcare professionals regarding post-acute care to be inadequate. Lack of information sharing, clinical notes and recommendations for the GP setting resulted in inefficient provision of support, as GPs feel limited in their ability to act., Discussion: Sharing necessary information with the GP setting could promote patient-centred care for people living with dementia and facilitate appropriate and timely resource allocation and effective healthcare collaboration between the settings, for example, by defining clear care pathways and clarifying roles and expectations., (© 2024. The Author(s).)

Background: Type 2 diabetes mellitus (T2DM) is a major health problem in the western world. Despite a widespread implementation of integrated care programs there are still patients with poorly controlled T2DM. Shared goal setting within the process of Shared Decision Making (SDM) may increase patient's compliance and adherence to treatment regimen. In our secondary analysis of the cluster-randomized controlled DEBATE trial, we investigated if patients with shared vs. non-shared HbA1c treatment goal, achieve their glycemic goals., Methods: In a German primary care setting, we collected data before intervention at baseline, 6, 12 and 24 months. Patients with T2DM with an HbA1c ≥ 8.0% (64 mmol/mol) at the time of recruitment and complete data at baseline and after 24 months were eligible for the presented analyses. Using a generalized estimating equation analysis, we analysed the association between the achievement of HbA1c goals at 24 months based on their shared vs. non-shared status, age, sex, education, partner status, controlled for baseline HbA1c and insulin therapy., Results: From N = 833 recruited patients at baseline, n = 547 (65.7%) from 105 General Practitioners (GPs) were analysed. 53.4% patients were male, 33.1% without a partner, 64.4% had a low educational level, mean age was 64.6 (SD 10.6), 60.7% took insulin at baseline, mean baseline HbA1c was 9.1 (SD 1.0). For 287 patients (52.5%), the GPs reported to use HbA1c as a shared goal, for 260 patients (47.5%) as a non-shared goal. 235 patients (43.0%) reached the HbA1c goal after two years, 312 patients (57.0%) missed it. Multivariable analysis shows that shared vs. non-shared HbA1c goal setting, age, sex, and education are not associated with the achievement of the HbA1c goal. However, patients living without a partner show a higher risk of missing the goal (p = .003; OR 1.89; 95% CI 1.25-2.86)., Conclusions: Shared goal setting with T2DM patients targeting on HbA1c-levels had no significant impact on goal achievement. It may be assumed, that shared goal setting on patient-related clinical outcomes within the process of SDM has not been fully captured yet., Trial Registration: The trial was registered at ISRCTN registry under the reference ISRCTN70713571., (© 2023. The Author(s).)

Introduction: Subjective cognitive decline (SCD) and depressive symptoms (DS) frequently co-occur prior to dementia. However, the temporal sequence of their emergence and their combined prognostic value for cognitive decline and dementia is unclear., Methods: Temporal relationships of SCD, DS and memory decline were examined by latent difference score modeling in a high-aged, population-based cohort (N = 3217) and validated using Cox-regression of dementia-conversion. In 334 cognitively unimpaired SCD-patients from memory-clinics, we examined the association of DS with cognitive decline and with cerebrospinal fluid (CSF) Alzheimer's disease (AD) biomarkers., Results: In the population-based cohort, SCD preceded DS. High DS were associated with increased risk of dementia conversion in individuals with SCD. In SCD-patients from memory-clinics, high DS were associated with greater cognitive decline. CSF Aß42 predicted increasing DS., Discussion: SCD typically precedes DS in the evolution to dementia. SCD-patients from memory-clinics with DS may constitute a high-risk group for cognitive decline., Highlights: Subjective cognitive decline (SCD) precedes depressive symptoms (DS) as memory declines. Emerging or persistent DS after SCD reports predict dementia. In SCD patients, more amyloid pathology relates to increasing DS. SCD patients with DS are at high risk for symptomatic progression., (© 2022 The Authors. Alzheimer's & Dementia published by Wiley Periodicals LLC on behalf of Alzheimer's Association.)

Background: Subjective memory complaints and family history of dementia are possibly intertwined risk factors for the own subsequent dementia risk and Alzheimer's disease. However, their interaction has rarely been studied., Objective: To study the association between subjective memory complaints and family history of dementia with regard to the own subsequent risk of dementia., Methods: Cross-sectional and longitudinal analyses over a follow-up period of up to 13 years were conducted in a population sample of participants without dementia at baseline (n = 3,256, mean age = 79.62 years), using group comparisons and Cox proportional hazards models., Results: Cross-sectionally, participants with subjective memory complaints were significantly more likely to report family history of dementia. Longitudinally, family history of dementia (FH) was significantly associated with subsequent dementia in the subjective memory complaints (SMC) group, but not in those without SMC. A relative excess risk due to interaction analysis confirmed a significant FHxSMC-interaction., Conclusions: Family history of dementia was a predictor of incident dementia in those with SMC, which can serve as an additional, clinically relevant criterion to gauge the risk of dementia in older-aged subjects with SMC with and without objective cognitive impairment.

Background. Vitamins A, D and E and beta-carotene may have a protective function for cognitive health, due to their antioxidant capacities. Methods. We analyzed data from 1334 non-demented participants (mean age 84 years) from the AgeCoDe study, a prospective multicenter-cohort of elderly general-practitioner patients in Germany, of whom n = 250 developed all-cause dementia and n = 209 developed Alzheimer’s dementia (AD) during 7 years of follow-up. We examined whether concentrations of vitamins A (retinol), D (25-hydroxycholecalciferol) and E (alpha-tocopherol) and beta-carotene, would be associated with incident (AD) dementia. Results. In our sample, 33.7% had optimum vitamin D concentrations (≥50 nmol/L). Higher concentrations of vitamin D were associated with lower incidence of all-cause dementia and AD (HR 0.99 (95%CI 0.98; 0.99); HR0.99 (95%CI 0.98; 0.99), respectively). In particular, subjects with vitamin D deficiency (25.3%, <25 nmol/L) were at increased risk for all-cause dementia and AD (HR1.91 (95%CI 1.30; 2.81); HR2.28 (95%CI 1.47; 3.53), respectively). Vitamins A and E and beta-carotene were unrelated to (AD) dementia. Conclusions. Vitamin D deficiency increased the risk to develop (AD) dementia. Our study supports the advice for monitoring vitamin D status in the elderly and vitamin D supplementation in those with vitamin D deficiency. We observed no relationships between the other vitamins with incident (AD) dementia, which is in line with previous observational studies.

Introduction: Several lifestyle factors promote protection against Alzheimer's disease (AD) throughout a person's lifespan. Although such protective effects have been described for occupational cognitive requirements (OCR) in midlife, it is currently unknown whether they are conveyed by brain maintenance (BM), brain reserve (BR), or cognitive reserve (CR) or a combination of them., Methods: We systematically derived hypotheses for these resilience concepts and tested them in the population-based AgeCoDe cohort and memory clinic-based AD high-risk DELCODE study. The OCR score (OCRS) was measured using job activities based on the O*NET occupational classification system. Four sets of analyses were conducted: (1) the interaction of OCR and APOE-ε4 with regard to cognitive decline (N = 2,369, AgeCoDe), (2) association with differentially shaped retrospective trajectories before the onset of dementia of the Alzheimer's type (DAT; N = 474, AgeCoDe), (3) cross-sectional interaction of the OCR and cerebrospinal fluid (CSF) AD biomarkers and brain structural measures regarding memory function (N = 873, DELCODE), and (4) cross-sectional and longitudinal association of OCR with CSF AD biomarkers and brain structural measures (N = 873, DELCODE)., Results: Regarding (1), higher OCRS was associated with a reduced association of APOE-ε4 with cognitive decline (mean follow-up = 6.03 years), consistent with CR and BR. Regarding (2), high OCRS was associated with a later onset but subsequently stronger cognitive decline in individuals converting to DAT, consistent with CR. Regarding (3), higher OCRS was associated with a weaker association of the CSF Aβ42/40 ratio and hippocampal volume with memory function, consistent with CR. Regarding (4), OCR was not associated with the levels or changes in CSF AD biomarkers (mean follow-up = 2.61 years). We found a cross-sectional, age-independent association of OCRS with some MRI markers, but no association with 1-year-change. OCR was not associated with the intracranial volume. These results are not completely consistent with those of BR or BM., Discussion: Our results support the link between OCR and CR. Promoting and seeking complex and stimulating work conditions in midlife could therefore contribute to increased resistance to pathologies in old age and might complement prevention measures aimed at reducing pathology., Competing Interests: ME receives research funding and consulting fees from Eli Lilly and Company. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Kleineidam, Wolfsgruber, Weyrauch, Zulka, Forstmeier, Roeske, van den Bussche, Kaduszkiewicz, Wiese, Weyerer, Werle, Fuchs, Pentzek, Brettschneider, König, Weeg, Bickel, Luppa, Rodriguez, Freiesleben, Erdogan, Unterfeld, Peters, Spruth, Altenstein, Lohse, Priller, Fliessbach, Kobeleva, Schneider, Bartels, Schott, Wiltfang, Maier, Glanz, Incesoy, Butryn, Düzel, Buerger, Janowitz, Ewers, Rauchmann, Perneczky, Kilimann, Görß, Teipel, Laske, Munk, Spottke, Roy, Brosseron, Heneka, Ramirez, Yakupov, Scherer, Maier, Jessen, Riedel-Heller and Wagner.)

Purpose: Higher Fit fOR The Aged (FORTA) scores have been shown to be negatively associated with adverse clinical outcomes in older hospitalized patients. This has not been evaluated in other health care settings. The aim of this study was to examine the association of the FORTA score with relevant outcomes in the prospective AgeCoDe-AgeQualiDe cohort of community-dwelling older people. In particular, the longitudinal relation between the FORTA score and mortality and the incidence of dementia was evaluated., Methods: Univariate and multivariate correlations between the FORTA score and activities of daily living (ADL) or instrumental activities of daily living (IADL) as well as comparisons between high vs. low FORTA scores were conducted., Results: The FORTA score was significantly correlated with ADL/IADL at baseline and at all follow-up visits (p < 0.0001). ADL/IADL results of participants with a low FORTA score were significantly better than in those with high FORTA scores (p < 0.0001). The FORTA score was also significantly (p < 0.0001) correlated with ADL/IADL in the multivariate analysis. Moreover, the mean FORTA scores of participants with dementia were significantly higher (p < 0.0001) than in those without dementia at follow-up visits 6 through 9. The mean FORTA scores of participants who died were significantly higher than those of survivors at follow-up visits 7 (p < 0.05), 8 (p < 0.001), and 9 (p < 0.001)., Conclusion: In this study, an association between higher FORTA scores and ADL as well as IADL was demonstrated in community-dwelling older adults. Besides, higher FORTA scores appear to be linked to a higher incidence of dementia and even mortality., (© 2022. The Author(s).)

Aim: The aim of this study was to investigate the frequency of and the gender differences in the use of professional home care in Germany., Methods: We used harmonized data from three large cohort studies from Germany ("Healthy Aging: Gender-specific trajectories into the latest life"; AgeDifferent.de Platform). Data were available for 5,393 older individuals (75 years and older). Mean age was 80.2 years (SD: 4.1 years), 66.6% were female. Professional homecare outcome variables were use of outpatient nursing care, paid household assistance, and meals on wheels' services. Logistic regression models were used, adjusting for important sociodemographic variables., Results: Altogether 5.2% of older individuals used outpatient nursing care (6.2% women and 3.2% men; p < 0.001), 24.2% used paid household assistance (26.1% women and 20.5% men; p < 0.001) and 4.4% used meals on wheels' services (4.5% women and 4.0% men; p = 0.49). Regression analysis revealed that women had higher odds of using paid household assistance than men (OR = 1.48, 95% CI: [1.24-1.76]; p < 0.001), whereas they had lower odds of using meals on wheels' services (OR = 0.64, 95% CI: [0.42-0.97]; p < 0.05). No statistically significant differences in using outpatient nursing care between women and men were found (OR = 1.26, 95% CI: [0.87-1.81]; p = 0.225). Further, the use of home care was mainly associated with health-related variables (e.g., stroke, Parkinson's disease) and walking impairments., Conclusions: Our study showed that gender differences exist in using paid household assistance and in culinary dependency. For example, meals on wheels' services are of great importance (e.g., for individuals living alone or for individuals with low social support). Gender differences were not identified regarding outpatient nursing care. Use of professional home care services may contribute to maintaining autonomy and independence in old age., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Buczak-Stec, Hajek, Pabst, Brettschneider, van den Bussche, Wiese, Weyerer, Werle, Hoell, Pentzek, Fuchs, Luppa, Löbner, Stein, Förster, Weeg, Mösch, Heser, Scherer, Maier, Angermeyer, Wagner, Riedel-Heller and König.)

Objectives: Autonomy (defined as self-governance; not equivalent to independence) is relevant to well-being and psychological functioning. However, there is a lack of research on individuals aged >85 years and their perception of autonomy when receiving informal care. This study aims to answer the question if and how the receipt of informal care is associated with perceived autonomy of individuals aged over 85 years., Method: A cross-sectional study was conducted with data from follow-up 9 of the AgeQualiDe study (2015/2016), which is a multi-centric prospective cohort study in Germany. The analytical sample included 570 participants aged >85 years and with a score of ≥ 19 on the Mini-Mental-State-Examination. Perceived autonomy was assessed with the Perceived Autonomy in Old Age Scale. Receipt of care was assessed as performance of at least one care task (help with basic and instrumental activities of daily living, and supervision) by relatives or friends. Sociodemographic information, mental health, functional level and receipt of professional ambulatory care were controlled for., Results: Unadjusted and adjusted linear regression analyses indicated a significant negative association between receipt of informal care and perceived autonomy. The results remained stable in sensitivity analyses; no significant interaction effect was found for gender or education., Conclusion: Findings indicate that informal care recipients aged >85 years perceive lower autonomy compared to those not receiving care. Additional or other forms of support, and improving the care relationship and communication might be considered to support autonomy of care recipients aged >85 years.

Introduction: Only a few studies have investigated incidence and risk factors of depression in the highest age groups. This study aims to determine incidence rates as well as risk factors of incident depressive symptoms in latest life, adjusting for the competing event of mortality., Methods: Data of a prospective, longitudinal, multi-centered cohort study conducted in primary care - the AgeCoDe-/AgeQualiDe study. 2436 GP patients aged 75+ years were assessed from baseline to sixth follow-up every 18 months and from seventh to ninth follow-up every 10 months. Depressive symptoms were assessed using the 15-item version of the Geriatric Depression Scale (cut-off ≥6). Competing risk regression models were used to assess determinants of incident depressive symptoms, taking care of accumulated mortality., Results: The incidence of depressive symptoms was 39 per 1000 person-years (95% CI 36-42; last observed exit 13.26 person-years at risk). In a competing risk regression model, female sex, unmarried family status, subjective cognitive decline as well as vision and mobility impairment were significant risk factors of incident depression., Limitations: Excluding individuals with a lack of ability to provide informed consent at baseline may have influenced the incidence of depression. Depressive symptoms were not assessed by DSM criteria. Furthermore, in studies with voluntary participation, participation bias can never be completely avoided., Conclusion: Findings provide a better understanding of risk and protective factors of depressive symptoms in the oldest age taking mortality as a competing event into account. Addressing this aspect in future research may yield new insights in that research field., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Purpose: Social isolation is considered a risk factor for dementia. However, less is known about social isolation and dementia with respect to competing risk of death, particularly in the oldest-old, who are at highest risk for social isolation, dementia and mortality. Therefore, we aimed to examine these associations in a sample of oldest-old individuals., Methods: Analyses were based on follow-up (FU) 5-9 of the longitudinal German study AgeCoDe/AgeQualiDe. Social isolation was assessed using the short form of the Lubben Social Network Scale (LSNS-6), with a score ≤ 12 indicating social isolation. Structured interviews were used to identify dementia cases. Competing risk analysis based on the Fine-Gray model was conducted to test the association between social isolation and incident dementia., Results: Excluding participants with prevalent dementia, n = 1,161 individuals were included. Their mean age was 86.6 ( SD = 3.1) years and 67.0% were female. The prevalence of social isolation was 34.7% at FU 5, 9.7% developed dementia and 36.0% died during a mean FU time of 4.3 ( SD = 0.4) years. Adjusting for covariates and cumulative mortality risk, social isolation was not significantly associated with incident dementia; neither in the total sample (sHR: 1.07, 95%CI 0.65-1.76, p = 0.80), nor if stratified by sex (men: sHR: 0.71, 95%CI 0.28-1.83, p = 0.48; women: sHR: 1.39, 95%CI 0.77-2.51, p = 0.27)., Conclusion: In contrast to the findings of previous studies, we did not find an association between social isolation and incident dementia in the oldest-old. However, our analysis took into account the competing risk of death and the FU period was rather short. Future studies, especially with longer FU periods and more comprehensive assessment of qualitative social network characteristics (e.g., loneliness and satisfaction with social relationships) may be useful for clarification., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Grothe, Röhr, Luppa, Pabst, Kleineidam, Heser, Fuchs, Pentzek, Oey, Wiese, Lühmann, van den Bussche, Weyerer, Werle, Weeg, Bickel, Scherer, König, Hajek, Wagner and Riedel-Heller.)

Purpose: The aim of this study was to examine the longitudinal within-association between social support and health-related quality of life among the oldest old., Methods: Longitudinal data (follow-up waves 7 to 9) 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). n = 648 individuals were included in the analytical sample. At FU wave 7, mean age was 88.8 years (SD: 2.9 years, from 85 to 99 years). Social support was quantified using the Lubben Social Network Scale (6-item version). Health-related quality of life was assessed using the EQ-5D-3L including problems in five health dimensions, and its visual analogue scale (EQ VAS). It was adjusted for several covariates in conditional logistic and linear fixed effects regressions., Results: Intraindividual decreases in social support were associated with an increased likelihood of developing problems in 'self-care', 'usual activities', 'pain/discomfort' and 'anxiety/depression' (within individuals over time). In contrast, intraindividual changes in social support were not associated with intraindividual changes in the EQ VAS score., Conclusion: Findings indicate a longitudinal intraindividual association between social support and problems, but only in some health dimensions. Further research in this area based on longitudinal studies among the oldest old (from different countries) is required., (© 2021. The Author(s).)

Objective: Since there is a lack of longitudinal studies in this area, our aim was to identify the determinants of persistent frequent attendance in primary care among the oldest old in Germany., Methods: Longitudinal data (follow-up wave 7-9) were taken from the multicenter prospective cohort "Study on needs, health service use, costs, and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe), covering primary care patients ≥ 85 years (FU7 n = 741, mean age 88.9 years (SD 2.9; 85-100)). Persistent frequent attenders of general practitioner (GP) services (the patients in the top decile of the number of GP consultations in two or more consecutive waves) were our main outcome of interest. Logistic random-effects models were used., Results: Our analysis included 1,891 observations (766 individuals). Across three waves, we identified 56 persistent frequent attenders. Results of random-effects logistic regressions showed that the odds of being persistent frequent attender were higher for widowed individuals (OR = 4.57; 95% CI [1.07-19.45]). Moreover, a one-point increase in the frailty score and having one more chronic condition increased the odds of being a persistent frequent attender by 68% (OR =1.68; 95% CI [1.05-2.69]) and 23% (OR=1.23, 95% CI [1.05-1.44]), respectively., Conclusion: Our study stressed the longitudinal association between frailty and widowhood as well as chronic diseases and persistent frequent attendance among the oldest old in Germany., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Buczak-Stec, Hajek, van den Bussche, Eisele, Oey, Wiese, Weyerer, Werle, Fuchs, Pentzek, Luppa, Löbner, Weeg, Mösch, Heser, Wagner, Riedel-Heller, Maier, Scherer and König.)

Background: In Germany, there are neither guidelines provided by the medical associations nor a public discussion about general practitioners (GPs) treating their family members. Only few studies on this topic from the primary care setting exist. The aim of this study is to describe GPs' treatment of family members and to generate empirical data on the most common reasons for this., Methods: In June 2018 we conducted a postal survey among GPs in the North Rhine region of Germany. The questionnaire was developed in a stepwise process including initial expert panels, interviews with GPs, item construction workshops, cognitive pre-tests and pilot testing with 40 questionnaires. The final questionnaire addressed: type and frequency of treatment, documentation and place of treatment, engagement as the official GP as well as reasons for and against the treatment. For data evaluation, descriptive and explorative statistical analyses were conducted., Results: Overall, 393 questionnaires were returned (response rate 39.8%). 96.7% of the GPs had treated at least one family member during the last 12 months. Services that were provided frequently (more than three times in the last 12 months) included the prescription or dispensing of medication (partner 45%, children 37%, parents 43%, partner's parents 26%), physical examinations (partner 18%, children 24%, parents 25%, partner's parents 15%), and the arrangement or provision of laboratory tests (partner 14%, children 7%, parents 16%, partner's parents 9%). Less than one third of the study participants always treated their relatives in their office. Male GPs more often provided care to family members (except children) registered in their practice. Senior male GPs treated their relatives more often than junior female GPs. Family members were most commonly treated for practical reasons., Conclusion: The subject of GPs treating their relatives is of high everyday relevance, since nearly all GPs are involved in the treatment of their family members. Frequent at-home treatments and low documentation rates may indicate risks due to deviating from the professional routine., (© 2022. The Author(s).)

Objective: Health scientists strive for a smooth recruitment of physicians for research projects like surveys. Teaching physicians are an easy to approach population that is already affiliated with a university by teaching students in their practice. How do response rates compare between a convenient online survey among teaching physicians and an elaborate postal survey in a random sample of unknown physicians? Data from the TMI-GP study on the use of memory tests in general practice were used., Results: Physicians in the random sample responded to the postal survey more often than teaching physicians to the online survey (59.5% vs. 18.9%; odds ratio 7.06; 95% confidence interval 4.81-10.37; p < 0.001). Although it is unclear whether the sample, the survey mode (online vs. postal) or both account for this effect, it is noteworthy that even in such a convenience sample of known/committed physicians, an adequate response rate could not be reached without a tailored and elaborated survey technique. Responders in the two samples were comparable regarding a content-related item (use of memory tests; Χ 2 (df = 1) = 3.07; p = 0.080)., (© 2021. The Author(s).)

Objective: Longitudinal studies investigating the link between social support and functional decline are limited among the oldest old. Thus, the aim of this study was to examine whether changes in social support are associated with functional decline among the oldest old longitudinally using panel regression models., Methods: Longitudinal data from 3 waves (waves 7, 8, and 9) of a multicenter prospective cohort study covering primary care patients aged ≥85 years were used. In the analytical sample, n equaled 624 individuals. The validated Lawton and Brody Instrumental Activities of Daily Living (IADL) scale and the well-established Barthel Index (ADL) were used to quantify functional status. The psychometrically sound Lubben Social Network Scale was used to measure social support. Several potential confounders such as age, marital status, cognitive decline, or depressive symptoms were included in the fixed effects (FE) regression models., Results: Linear FE regressions showed that a decrease in social support is associated with functional decline (IADL: β = 0.03, p < 0.05; ADL: β = 0.27, p < 0.05) in men but not in women. With IADL as outcome measure, the interaction term (sex × social support) achieved statistical significance (p < 0.01). With regard to covariates, functional decline (IADL and ADL) was consistently associated with increasing age, an increase in the number of chronic conditions (except for women [ADL]), and cognitive decline (except for men [ADL]). Furthermore, functional decline (ADL) was associated with an increase in depressive symptoms., Discussion: Our findings highlight the meaning of social support for functional status among the oldest old. Finding ways to sustain social support in highest age may be a promising approach in order to postpone functional decline., (© 2021 S. Karger AG, Basel.)

Introduction: Due to the strong association between old age and the need for long-term care, the number of individuals in need for care is projected to increase noticeably. The aim of this study was to examine the determinants of institutionalization among the oldest old longitudinally., Methods: Longitudinal data (follow-up [FU] wave 7-9) were gathered from a multicenter prospective cohort study ("Study on needs, health service use, costs and health-related quality of life in a large sample of oldest old primary care patients [85+]," AgeQualiDe). At FU wave 7, in 2014, complete measures were available for 763 individuals. The average age was 88.9 (standard deviation 2.9) years (range 85-100), and 68% were female. Sociodemographic and health-related independent variables (e.g., depressive symptoms or functioning) were included in the regression model. Institutionalization (admission to assisted living home or nursing home) was used as an outcome measure. Logistic random-effects models were used., Results: Regressions revealed that among oldest old, the odds of being institutionalized were lower for men (odds ratio [OR] = 0.03; 95% confidence interval [CI] 0.00-0.16). Institutionalization was associated with an increased age (OR = 1.27; 95% CI 1.04-1.55). Additionally, widowed individuals (ref. non-widowed) had higher odds of being institutionalized (OR = 8.95; 95% CI 1.61-49.81). Institutionalization was also associated with functional decline (OR = 0.16; 95% CI 0.11-0.23), whereas it was not significantly associated with cognitive decline, depressive symptoms, and social support., Conclusion: Our findings stress the importance of gender, age, widowhood, and functional decline for institutionalization among the oldest old. Preventing or at least postponing functional decline might help to delay institutionalization as far as possible., (© 2021 S. Karger AG, Basel.)

Research on anxiety in oldest-old individuals is scarce. Specifically, incidence studies based on large community samples are lacking. The objective of this study is to assess age- and gender-specific incidence rates in a large sample of oldest-old individuals and to identify potential risk factors. The study included data from N = 702 adults aged 81 to 97 years. Anxiety symptoms were identified using the short form of the Geriatric Anxiety Inventory (GAI-SF). Associations of potential risk factors with anxiety incidence were analyzed using Cox proportional hazard models. Out of the N = 702 older adults, N = 77 individuals developed anxiety symptoms during the follow-up period. The incidence rate was 51.3 (95% CI: 41.2-64.1) per 1000 person-years in the overall sample, compared to 58.5 (95% CI: 43.2-72.4) in women and 37.3 (95% CI: 23.6-58.3) in men. Multivariable analysis showed an association of subjective memory complaints (HR: 2.03, 95% CI: 1.16-3.57) and depressive symptoms (HR: 3.20, 95% CI: 1.46-7.01) with incident anxiety in the follow-up. Incident anxiety is highly common in late life. Depressive symptoms and subjective memory complaints are major risk factors of new episodes. Incident anxiety appears to be a response to subjective memory complaints independent of depressive symptoms.

Objectives: The extent of university teaching in general practice is increasing and is in part realised with attachments in resident general practices. The selection and quality management of these teaching practices pose challenges for general practice institutes; appropriate instruments are required. The question of the present study is whether the student evaluation of an attachment in previously poorly evaluated practices improves after teaching physicians have received feedback from a colleague. Methods: Students in study years 1, 2, 3 and 5 evaluated their experiences in general practice attachments with two 4-point items (professional competence and recommendation for other students). Particularly poorly evaluated teaching practices were identified. A practising physician with experience in teaching and research conducted a personal feedback of the evaluation results with these (peer feedback), mainly in the form of individual discussions in the practice (peer visit). After this intervention, further attachments took place in these practices. The influence of the intervention (pre/post) on student evaluations was calculated in generalised estimating equations (cluster variable practice). Results: Of 264 teaching practices, 83 had a suboptimal rating. Of these, 27 practices with particularly negative ratings were selected for the intervention, of which 24 got the intervention so far. There were no post-evaluations for 5 of these practices, so that data from 19 practices (n=9 male teaching physicians, n=10 female teaching physicians) were included in the present evaluation. The evaluations of these practices were significantly more positive after the intervention (by n=78 students) than before (by n=82 students): odds ratio 1.20 (95% confidence interval 1.10-1.31; p<.001). Conclusion: The results suggest that university institutes of general practice can improve student evaluation of their teaching practices via individual collegial feedback., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2021 Pentzek et al.)

Background: It is almost unknown whether the driving status is associated with HRQOL among individuals in highest age., Aims: Based on a multicenter prospective cohort study, the objective of this study was to examine whether the driving status is associated with health-related quality of life (HRQOL) among the oldest old in Germany., Methods: Cross-sectional data from follow-up wave 9 (n = 544) were derived from the "Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe). Average age was 90.3 years (± 2.7; 86 to 101 years). The current driver status (no; yes) was used in our analysis. The EuroQoL EQ-5D questionnaire was used to assess HRQOL in this study., Results: Regression analysis showed that being a current driver was associated with the absence of problems in 'self-care' [OR 0.41 (95%-CI 0.17 to 0.98)], and 'usual activities' [OR 0.48 (0.26 to 0.90)], whereas it was not significantly associated with problems in 'pain/discomfort' [OR  0.82 (0.47 to 1.45)] and 'anxiety/depression' [OR  0.71 (0.36 to 1.39)]. Being a current driver was marginally significantly associated with the absence of problems in 'mobility' [OR 0.60 (0.34 to 1.06)]. While being a current driver was not associated with the EQ-VAS in the main model, it was positively associated with the driving status (β = 5.00, p < .05) when functional impairment was removed from the main model., Discussion: Our findings provide first evidence for an association between driving status and HRQOL among the oldest old., Conclusions: Future longitudinal studies are required to evaluate a possible causal relationship between driving status and HRQOL in very old individuals., (© 2020. The Author(s).)

Background: Legally recognized advance directives (ADs) have to be signed by the person to whom the decisions apply. In practice, however, there are also ADs written and signed by legal proxies (surrogates) on behalf of patients who lack decision-making capacity. Given their practical relevance and substantial ethical and legal implications, ADs by proxy (AD-Ps) have received surprisingly little scientific attention so far., Objectives: To study the form, content, validity, and applicability of AD-Ps among German nursing home residents and develop policy implications., Methods: Secondary analysis of two independent cross-sectional studies in three German cities, comprising 21 nursing homes and 1528 residents. The identified AD-Ps were analyzed in parallel by three independent raters. Inter-rater agreement was measured using free-marginal multi-rater kappa statistics., Results: Altogether, 46 AD-Ps were identified and pooled for analysis. On average (range), AD-Ps were 1 (1-7) year(s) old, 0.5 (0.25-4) pages long, signed by 1 (0-5) person, with evidence of legal proxy involvement in 35%, and signed by a physician in 20% of cases. Almost all the AD-Ps reviewed aimed to limit life-sustaining treatment (LST), but had widely varying content and ethical justifications, including references to earlier statements (30%) or actual behavior (11%). The most frequent explicit directives were: do-not-hospitalize (67%), do-not-tube-feed (37%), do-not-attempt-resuscitation (20%), and the general exclusion of any LST (28%). Inter-rater agreement was mostly moderate (kappa ≥0.6) or strong (kappa ≥0.8)., Conclusions: Although AD-Ps are an empirical reality in German nursing homes, formal standards for such directives are lacking and their ethical justification based on substituted judgment or best interest standard often remains unclear. A qualified advance care planning process and corresponding documentation are required in order to safeguard the appropriate use of this important instrument and ensure adherence to ethico-legal standards., (© 2021 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Purpose: To investigate the association between health-related quality of life and ego integrity among the oldest old., Materials and Methods: Cross-sectional data were taken from follow-up wave 9 of 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). Our analytical sample comprised n = 495 observations. Mean age was 90.2 years (SD: 2.7 years). Health-related quality of life was quantified using the EQ-5D-3L questionnaire (including the visual analogue scale EQ-VAS). Ego integrity was measured using the Ego Integrity Scale., Results: Regressions showed an association between decreased ego integrity and problems with 'usual activities', 'pain/discomfort' and 'anxiety/depression'. Furthermore, regressions showed a marginally significant association between decreased ego integrity and problems with 'mobility' and a decreased EQ-VAS score. Ego integrity was not significantly associated with problems with 'self-care'., Conclusions: Findings stress the importance of health-related quality of life for ego integrity among the oldest old. Future studies are required to clarify the underlying mechanisms., (Copyright © 2021. Published by Elsevier B.V.)

Objectives: There is a lack of studies identifying the correlates of institutionalization specifically among the oldest old. Therefore, our aim was to fill this gap in knowledge., Methods: Cross-sectional data (Follow up wave 9; n = 633 observations in the analytical sample) were used from the multicenter prospective cohort study "Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" Correlates of institutionalization among the oldest old-Evidence from a multicenter cohort study. The sample consists of primary care patients aged 86 years and over (mean 90.5 years, SD: 2.9 years). Sociodemographic and health-related independent variables were included in our regression model. Institutionalization was defined as living in a nursing home or an old-age home (not including assisted living facilities)., Results: Out of the 633 participants, 502 individuals (79.3%) did not live in an institutionalized setting, whereas 73 individuals (20.7%) lived in an institutionalized setting. Multiple logistic regressions showed that the likelihood of institutionalization increased with being divorced/widowed/single (compared to being married; OR: 5.35 [95% CI: 1.75-16.36]), the presence of social isolation (OR: 2.07 [1.20-3.59]), more depressive symptoms (OR: 1.11 [1.01-1.23]), increased cognitive impairment (OR: 1.67 [1.31-2.15]) and higher levels of frailty (OR: 1.48 [1.07-2.06])., Conclusion: The study findings identified various sociodemographic and health-related factors associated with institutionalization among the oldest old. Longitudinal studies are required to gain further insights into these associations., (© 2021 The Authors. International Journal of Geriatric Psychiatry published John Wiley & Sons Ltd.)

Widowhood is common in old age, can be accompanied by serious health consequences and is often linked to substantial changes in social network. Little is known about the impact of social isolation on the development of depressive symptoms over time taking widowhood into account. We provide results from the follow-up 5 to follow-up 9 from the longitudinal study AgeCoDe and its follow-up study AgeQualiDe. Depression was measured with GDS-15 and social isolation was assessed using the Lubben Social Network Scale (LSNS-6). The group was aligned of married and widowed people in old age and education through entropy balancing. Linear mixed models were used to examine the frequency of occurrence of depressive symptoms for widowed and married elderly people depending on the risk of social isolation. Our study shows that widowhood alone does not lead to an increased occurrence of depressive symptoms. However, "widowed oldest old", who are also at risk of social isolation, have significantly more depressive symptoms than those without risk. In the group of "married oldest old", women have significantly more depressive symptoms than men, but isolated and non-isolated do not differ. Especially for people who have lost a spouse, the social network changes significantly and increases the risk for social isolation. This represents a risk factor for the occurrence of depressive symptoms.

Background: We investigate whether an educational intervention of GPs increases patient-centeredness and perceived shared decision making in the treatment of patients with poorly controlled type 2 diabetes mellitus?, Methods: We performed a cluster-randomized controlled trial in German primary care. Patients with type 2 diabetes mellitus defined as HbA1c levels ≥ 8.0% (64 mmol/mol) at the time of recruitment (n = 833) from general practitioners (n = 108) were included. Outcome measures included subjective shared decision making (SDM-Q-9; scale from 0 to 45 (high)) and patient-centeredness (PACIC-D; scale from 1 to 5 (high)) as secondary outcomes. Data collection was performed before intervention (baseline, T0), at 6 months (T1), at 12 months (T2), at 18 months (T3), and at 24 months (T4) after baseline., Results: Subjective shared decision making decreased in both groups during the course of the study (intervention group: -3.17 between T0 and T4 (95% CI: -4.66, -1.69; p < 0.0001) control group: -2.80 (95% CI: -4.30, -1.30; p = 0.0003)). There were no significant differences between the two groups (-0.37; 95% CI: -2.20, 1.45; p = 0.6847). The intervention's impact on patient-centeredness was minor. Values increased in both groups, but the increase was not statistically significant, nor was the difference between the groups., Conclusions: The intervention did not increase patient perceived subjective shared decision making and patient-centeredness in the intervention group as compared to the control group. Effects in both groups might be partially attributed to the Hawthorne-effect. Future trials should focus on patient-based intervention elements to investigate effects on shared decision making and patient-centeredness., Trial Registration: The trial was registered on March 10 th , 2011 at ISRCTN registry under the reference ISRCTN70713571 .

Objectives: This study aimed to examine aspects of help-seeking for psychological distress and its association with increased anxiety symptoms in the oldest old. Method: Baseline data from AgeQualiDe, a multicenter cohort study of people aged 85 and over recruited in primary care, were analyzed. Help-seeking for psychological distress (items from the Camberwell Assessment of Need for the Elderly) was analyzed using ordinal and logistic regression models as a function of increased anxiety symptoms (Geriatric Anxiety Inventory-Short Form ≥ 3), as well as relevant socio-demographic and health-related covariates. Results: N  = 155 (18.1% of the sample) reported having experienced psychological distress recently and were thus included in the analysis. Among those, 26.5% reported experiencing increased anxiety symptoms. On a descriptive level, 76.8% sought informal, 29.0% sought formal, and 18.1% sought no help for psychological distress. In covariate-adjusted regression models, increased anxiety was significantly associated with increased use of informal support (OR: 2.92, 95% CI: 1.31-6.48), but was neither associated with formal (OR: 0.72, 95% CI: 0.26-1.97) nor no help-seeking (OR: 0.28, 95% CI: 0.08-1.05). Conclusion: A large proportion of those experiencing psychological distress sought support from informal sources in this study. Anxiety symptoms in the oldest old were associated with the increased use of informal support, but not formal support or no help-seeking. Training and support for people providing informal help to those with mental health problems should be promoted to reduce a possible burden. However, future research addressing underlying mechanisms is needed.

Background: Increasingly more very old people are active drivers. Sensory, motor and cognitive limitations, and medication can increase safety risks. Timely attention to driving safety in the patient-doctor relationship can promote patient-centred solutions., Aim: To explore the following questions: do GPs know which patients drive a car? Is fitness to drive addressed with patients?, Design & Setting: Cross-sectional data from patient interviews and GP survey in the ninth follow-up phase of a prospective primary care cohort (the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe) and the Study on Needs, Health Service Use, Costs and Health-Related Quality of Life in a large sample of 'oldest-old' primary care patients (≥85 years; AgeQualiDe)) ., Method: The sample consisted of patients in the age group ≥85 years and their GPs. Independent reports were gathered on driving activity from the GP and the patient, and information was gained from GPs on whether driving ability was discussed with the patient. Statistical analyses included validity parameters and bivariate characterisation of subgroups (non-parametric significance tests, effect size)., Results: Self-reports of 553 patients were available (69.5% female; mean age 90.5 years; 15.9% drive a car). For 427 patients, GP data were also available: GPs recognised 67.1% correctly as drivers and 94.9% as non-drivers. GPs said that they had discussed fitness to drive with 32.1% of potentially driving patients. Among drivers who were not recognised and with whom driving had not been discussed, there were more patients with a low educational level., Conclusion: The GP's assessment of driving activity among very old patients showed moderate sensitivity and good specificity. Driving ability was seldom discussed. Asking an appropriate question during assessment could increase GPs' awareness of older patients' automobility., (Copyright © 2021, The Authors.)

Objective: 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., Design: 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)., Setting and Participants: Primary care patients aged 85 years and older., Methods: 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., Results: 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)., Conclusions and Implications: 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., (Copyright © 2020 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: There is a lack of studies examining the link between perceived autonomy and frailty among the oldest old. Therefore, our objective was to fill this gap., Methods: Data were used from the multicenter prospective cohort study "Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe; follow-up [FU] wave 9; n = 510 observations in the analytical sample). The average age was 90.3 years (SD: 2.7 years). The Canadian Study of Health and Aging (CSHA) Clinical Frailty Scale (CFS) was used to assess frailty. Socioeconomic and health-related covariates were included in our regression model. The autonomy scale developed by Schwarzer was used to assess perceived autonomy in old age., Results: Adjusting for various confounders, multiple linear regressions showed that lower perceived autonomy was associated with increased levels of frailty (total sample: β = -0.13, p < 0.001; women: β = -0.14, p < 0.001; and men: β = -0.12, p < 0.001). Furthermore, lower perceived autonomy was associated with more depressive symptoms, higher cognitive impairment, and being institutionalized (except for men) in the total sample and in both sexes, but it was not significantly associated with age, sex, marital status, educational level, and social support., Conclusion: Findings indicate that frailty is associated with lower autonomy among the oldest old. More generally, while health-related factors were consistently associated with autonomy, sociodemographic factors (except for being institutionalized) were not associated with autonomy among the oldest old. We should be aware of the strong association between autonomy and physical as well as mental health in very old age., (© 2021 S. Karger AG, Basel.)

Objectives: Previous studies have observed protective effects of high mental demands at work on cognitive functioning and dementia risk. However, it is unclear what types of demands drive this effect and whether this effect is subject to a person's genetic risk. We investigated to what extent eight different types of mental demands at work together with the APOE e4 allele, a major risk gene for late-onset Alzheimer's disease, affect cognitive functioning in late life., Methods/design: The population-based German Study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe, n = 2 154) followed cognitively healthy individuals aged 75 years and older in seven assessment waves. Cognitive functioning was assessed via the mini-mental status examination., Results: Mixed-effects modeling (adjusted for education, gender, marital status, stroke, depression, and diabetes) indicated that participants who had an occupational history of working in jobs with high compared to low demands in "Language & Knowledge", "Pattern detection", "Information processing", and "Service" had a slower cognitive decline. APOE e4-allele carriers had an accelerated cognitive decline, but this decline was significantly smaller if they had a medium compared to a low level of demands in contrast to non-carriers., Conclusions: Our longitudinal observations suggest that cognitive decline could be slowed by an intellectually enriched lifestyle even in risk gene carriers. Fostering intellectual engagement throughout the life-course could be a key prevention initiative to promote better cognitive health in old age., (© 2020 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons Ltd.)

The heterogeneity in the operationalisation of successful ageing (SA) hinders a straightforward examination of SA associations and correlates, and in turn, the identification of potentially modifiable predictors of SA. It is unclear which SA associations and correlates influence all facets of the SA construct, and whether psychosocial reserve models developed in neuropathological ageing research can also be linked to SA. It was therefore the aim of this study to disentangle the effect of various previously identified SA associations and correlates on (1) a general SA factor, which represents the shared underpinnings of three SA facets, and (2) more confined, specific factors, using bifactor modelling. The associations and correlates of three recently validated SA operationalisations were compared in 2478 participants from the German AgeCoDe study, aged 75 years and above. Based on participants' main occupation, cognitive reserve (CR) and motivational reserve (MR) models were built. Younger age, male gender, more education, higher socio-economic status, being married or widowed, as well as more physical exercise and cognitive activities in old age were found to correlate positively with the general SA factor, indicating a simultaneous effect on all aspects of SA. Smoking and ApoE-ε4 were related only to the physiological facet of SA. CR models were significantly related to the general SA factor. Among all SA associations and correlates, proxy indicators of lifelong cognitive activity and physical exercise showed the strongest effects on SA. Future intervention studies should assess the influence of the preservation of active lifestyle across the life span on SA., Competing Interests: Conflict of interestThe authors have no conflicts of interest to declare., (© The Author(s) 2020.)

Background: There are very few studies examining the determinants of frequent attendance in primary care among the oldest old., Aims: The purpose of this study was to determine the characteristics of frequent attendance among individuals aged 85 years or older., Methods: Cross-sectional data stem from the multicenter prospective cohort "Study on needs, health service use, costs and health-related quality of life in a large sample of oldest old primary care patients (85 +)" (AgeQualiDe). This study covers very old primary care patients (n = 861, mean age of 89.0 years ± 2.9; 85-100 years). The number of self-reported GP visits in the preceding 3 months was used to quantify frequent attenders. We defined patients in the top decile as frequent attenders., Results: Multiple logistic regressions showed that frequent attendance was associated with more chronic diseases (adjusted OR 1.12, 95% CI 1.01-1.23), worse functioning (OR 0.97, 95% CI 0.95-0.99), worries about one's financial situation (OR 2.20, 95% CI 1.07-4.53) and it was inversely associated with depression (OR 0.26, 95% CI 0.08-0.80)., Discussion: In contrast to studies based on younger samples, different factors were associated with frequent users in our study, showing that it is important to study the determinants of frequent attendance among the oldest old., Conclusion: In Germany, among the group of the oldest old, frequent attendance was positively associated with worse physical health status (e.g., number of chronic diseases), but negatively with depression. This might indicate that the German health care system is responsive to the physical, but not psychological needs of the oldest old.

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

Introduction: Subjective cognitive decline (SCD) is a risk condition for dementia, including dementia of Alzheimer type (DAT)., Methods: We report sensitivity, specificity, positive and negative predictive values (PPV, NPV) for conversion to all-cause dementia, and DAT in different SCD types (decline in memory, assocated worries, longitudinal consitency, of the AgeCoDe study (n = 2.402, 12 years follow-up)., Results: 82.7% of those converting to any dementia and 84.4% of those converting with DAT at follow-up, reported memory decline and fulfilled criteria of SCD at least at one time point before. SCD with worries at two consecutive time points showed a specificity of 92.2% for any dementia and also for DAT as well as a PPV of 44.3% for any dementia and of 36.9% for DAT at follow-up at the expense of low sensitivity., Discussion: Different SCD subtypes were either sensitive or specific for future all-cause dementia and DAT in cognitively unimpaired individuals. Modest PPV of the most specific SCD subtypes were achieved in this low prevalence population., (© 2020 the Alzheimer's Association.)

Background: Hospitalization is a key driver of health care costs. Thus far, there are only a few longitudinal studies investigating whether changes in explanatory variables lead to hospitalization. Moreover, these longitudinal studies did not focus on individuals in highest age., Aim: The purpose of the current study was to examine the correlates of hospitalization among the oldest old in Germany longitudinally., Methods: A multicenter prospective cohort study ["Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)", AgeQualiDe]. Primary care patients ≥ 85 years took part [n = 861 at follow-up (FU) 7, average age of 89.0 years; 85-100 years]. Two waves were used. Hospitalization in the last 6 months was used as outcome measure. Well-established scales were used to quantify the independent variables such as Instrumental Activities of Daily Living Scale, Global Deterioration Scale or Geriatric Depression Scale., Results: Logistic random effects regressions showed that the probability of hospitalization in the preceding 6 months significantly increased with increases in the social network, more depressive symptoms, functional decline, and increase in chronic conditions, whereas it was not significantly associated with age, sex, marital status, education, and cognitive impairment. Social networks moderate the relationship between functional decline and hospitalization., Discussion: The results of the present longitudinal study emphasize the association of depressive symptoms, functional decline, more social networks, and chronic conditions with hospitalization among the oldest old., Conclusions: Treatments with the aim to reduce or postpone these factors might also help to reduce hospitalization.

Purpose: To determine the prevalence of overweight and obesity, and to identify factors associated with obesity, among the oldest old., Methods: For this study, data from follow-up (FU) wave 7 and FU wave 8 of the "Study on Needs, Health Service Use, Costs and Health-Related Quality of Life in a Large Sample of Oldest-Old Primary Care Patients (85+)" (AgeQualiDe) were used. At FU wave 7, the mean age was 88.9 years (SD: 2.9; 85-100 years). Body-mass-index (BMI) categories were defined according to the World Health Organization (WHO) thresholds: underweight (BMI < 18.5 kg/m²), normal weight (18.5 kg/m² ≤ BMI < 25 kg/m²), overweight (25 kg/m² ≤ BMI < 30 kg/m²), and obesity (BMI ≥ 30 kg/m²). Longitudinal regression analysis was used to determine factors associated with obesity., Results: At FU wave 7, 3.0 % were underweight, 48.9 % were normal weight, 37.9 % were overweight, and 10.2 % were obese. Regressions showed that the probability of obesity decreased with age (OR: 0.77 [95 % CI: .593-.999]) and less chronic conditions (OR: 1.32 [95 % CI: 1.11-1.57]). The probability of obesity was not associated with sex, educational level, marital status, social isolation, visual impairment, hearing impairment, depression, and dementia., Conclusion: Nearly half of the individuals in very late life had excess weight. Thus, excess weight remains a major challenge, even in very old age. Given the demographic ageing in upcoming decades, this is an issue which we should be aware of., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

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

Objectives: Social isolation is increasing in aging societies and several studies have shown a relation with worse cognition in old age. However, less is known about the association in the oldest-old (85+); the group that is at highest risk for both social isolation and dementia., Methods: Analyses were based on follow-up 5 to 9 of the longitudinal German study on aging, cognition, and dementia in primary care patients (AgeCoDe) and the study on needs, health service use, costs, and health-related quality of life in a large sample of oldest-old primary care patients (AgeQualiDe), a multi-center population-based prospective cohort study. Measurements included the Lubben Social Network Scale (LSNS-6), with a score below 12 indicating social isolation, as well as the Mini-Mental Status Examination (MMSE) as an indicator of cognitive function., Results: Dementia-free study participants (n = 942) were M = 86.4 ( SD = 3.0) years old at observation onset, 68.2% were women. One third (32.3%) of them were socially isolated. Adjusted linear hybrid mixed effects models revealed significantly lower cognitive function in individuals with smaller social networks ( β = 0.5, 95% CI = 0.3-0.7, p < .001). Moreover, changes in an individual's social network size were significantly associated with cognitive changes over time ( β = 0.2, 95% CI = 0.1-0.4, p = .003), indicating worse cognitive function with shrinking social networks., Conclusion: Social isolation is highly prevalent among oldest-old individuals, being a risk factor for decreases in cognitive function. Consequently, it is important to maintain a socially active lifestyle into very old age. Likewise, this calls for effective ways to prevent social isolation., (Copyright © 2020 Röhr, Löbner, Gühne, Heser, Kleineidam, Pentzek, Fuchs, Eisele, Kaduszkiewicz, König, Brettschneider, Wiese, Mamone, Weyerer, Werle, Bickel, Weeg, Maier, Scherer, Wagner and Riedel-Heller.)

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

Objective: To clarify the link between depressive symptoms and functional impairment among the oldest old longitudinally., Methods: Longitudinal data (n = 1,272) were taken from a multicenter prospective cohort study ("Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" [AgeQualiDe]). Functional decline was assessed using the Lawton and Brody Instrumental Activities of Daily Living scale, and the Geriatric Depression Scale was used to measure depressive symptoms., Results: While initial increases in depressive symptoms were associated with subsequent increases in functional impairment, initial increases in functional impairment were not associated with subsequent increases in depressive symptoms., Conclusions: Our results stress the relevance of increases in depressive symptoms for upcoming functional decline among the oldest old. Further longitudinal studies are required to replicate our findings., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Past research has revealed a variety of olfactory deficits associated with psychiatric and neurodegenerative disorders. These deficits are evident in psychophysical olfactory testing as well as neurophysiological and neuroanatomical examinations. The specific type of olfactory dysfunction appears disorder specific. For example, with regard to affective disorders, the functional and anatomical overlap between olfactory and emotion-specific brain areas has been suggested as a major underlying factor for olfactory dysfunction. Based on converging evidence of changes in olfactory perception related to Major Depression, Schizophrenia, Alzheimer's and Parkinson's Disease, olfactory testing has been discussed as an important additional diagnostic marker. Hence, valid methods for objective and reliable olfactory testing as well as guidelines for the interpretation of the respective diagnostic findings are required. The aim of this review is to provide an overview of reported olfactory deficits in psychiatric and neurodegenerative disorders. In addition, a selection of olfactory tests, available in German-speaking countries, with regard to the respective disorder-related olfactory deficit in question are presented and classified. Original data regarding an empirical validation of the Düsseldorf Odour Discrimination Test in a clinical population are presented., Competing Interests: Die Autoren erklären, dass keine Interessenkonflikte bestehen., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: There is a lack of studies investigating the link between time-varying factors associated with changes in frailty scores in very old age longitudinally. This is important because the level of frailty is associated with subsequent morbidity and mortality., Objective: To examine time-dependent predictors of frailty among the oldest old using a longitudinal approach., Methods: Longitudinal data were drawn from the multicentre prospective cohort study "Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe), covering primary care patients aged 85 years and over. Three waves were used (from follow-up, FU, wave 7 to FU wave 9 [with 10 months between each wave]; 1,301 observations in the analytical sample). Frailty was assessed using the Canadian Study of Health and Aging (CSHA) Clinical Frailty Scale (CFS). As explanatory variables, we included sociodemographic factors (marital status and age), social isolation as well as health-related variables (depression, dementia, and chronic diseases) in a regression analysis., Results: In total, 18.9% of the individuals were mildly frail, 12.4% of the individuals were moderately frail, and 0.4% of the individuals were severely frail at FU wave 7. Fixed effects regressions revealed that increases in frailty were associated with increases in age (β = 0.23, p < 0.001), and dementia (β = 0.84, p < 0.01), as well as increases in chronic conditions (β = 0.03, p = 0.058)., Conclusion: The study findings particularly emphasize the importance of changes in age, probably chronic conditions as well as dementia for frailty. Future research is required to elucidate the underlying mechanisms. Furthermore, future longitudinal studies based on panel regression models are required to confirm our findings., (© 2020 S. Karger AG, Basel.)