Search

The biomedical approach to medical knowledge is widely accepted around the world. This article considers whether the incorporated aspects of physician-patient interaction have become similarly common across the globe by comparing the gestures that physicians use in their interactions with patients. Up to this point, there has been little research on physicians’ use of gestures in health-care settings. We explore how—in four university hospitals in Turkey, the People’s Republic of China, The Netherlands and Germany—physicians use gesture in their discussions with simulated patients about the condition of heart failure. Our analysis confirms the importance of gestures for organising both the personal interaction and the knowledge transfer between physician and patient. From the perspective of global comparison, it is notable that physicians in all four hospitals used similar gestures. This demonstrates the globality of biomedical knowledge in an embodied mode. Physicians used gestures for a range of purposes, including to convey the idea of an ‘anatomical map’ and for constructing visual models of (patho-)physiological processes. Since biomedical language is rife with metaphor, it was not surprising that we also identified an accompanying metaphorical gesture which has a similar form in the various locations that were part of the study. in press

Objective To describe and evaluate a consensus finding and expert validation process for the development of patient-centred communication assessments for a national Licensing Exam in Medicine. Methods A multi-professional team of clinicians and experts in communication, assessment and role-play developed communication assessments for the Swiss Federal Licensing Examination. The six-month process, informed by a preceding national needs-assessment, an expert symposium and a critical literature review covered the application of patient-centred communication frameworks, the development of assessment guides, concrete assessments and pilot-tests. The participants evaluated the process. Results The multiple-step consensus process, based on expert validation of the medical and communication content, led to six high-stakes patient-centred communication OSCE-assessments. The process evaluation revealed areas of challenge such as calibrating rating-scales and case difficulty to the graduates’ competencies and integrating differing opinions. Main success factors were attributed to the outcome-oriented process and the multi-professional exchange of expertise. A model for developing high stakes patient-centred communication OSCE-assessments was derived. Conclusions Consensus finding was facilitated by using well-established communication frameworks, by ensuring outcome-orientated knowledge exchange among multi-professional experts, and collaborative validation of content through experts. Practice implications We propose developing high-stakes communication assessments in a multi-professional expert consensus and provide a conceptual model.

Objective To present a guide for communication curriculum development in healthcare professions for educators and curriculum planners. Methods:\ We collated a selection of theories, frameworks and approaches to communication curriculum development to provide a roadmap of the main factors to consider when developing or enhancing communication skills curricula. Results We present an evidence-based guide for developing and enhancing communication curriculum that can be applied to undergraduate and postgraduate healthcare education. Recommended steps to consider during the communication curricula development process include thoughtful examination of current communication education, needs assessment, focused learning goals and objectives, incorporation of experiential educational strategies allowing for skills practice and feedback and use of formative and summative assessment methods. A longitudinal, developmental and helical implementation approach contributes to reinforcement and sustainment of learners’ knowledge and skills. Conclusion and Practice implications Drawing on best practices in developing communication curricula can be helpful in ensuring successful approaches to communication skills training for any level of learner or healthcare profession. This position paper provides a guide and identifies resources for new and established communication curriculum developers to reflect on strengths and opportunities in their own approaches to addressing the communication education needs of their learners.

Objectives Effective instructional approaches are needed to enable undergraduates to optimally prepare for the limited training time they receive with simulated patients (SPs). This study examines the learning effects of different presentation formats of a worked example on student SP communication. Methods Sixty-seven fourth-year medical students attending a mandatory communication course participated in this randomized field trial. Prior to the course, they worked through an e-learning module that introduced the SPIKES protocol for delivering bad news to patients. In this module, a single worked example was presented to one group of students in a text version, to a second group in a video version, and to a third group in a video version enriched with text hints denoting the SPIKES steps. Results The video-with-hints group broke bad news to SPs significantly more appropriately than either of the other groups. Although no further condition-related effects were revealed, students who learned from the text version most frequently (although non-significantly) ignored unpleasant emotions (standardised emotional cues and concerns) expressed by the SPs. Conclusions The learning effect was strongest when the video-based worked example was accompanied by hints. Practice implications Video-related learning approaches that embed attention-guiding hints can effectively prepare undergraduates for SP encounters.

Introduction Previous studies have demonstrated that an overall high level of mental work demands decreased dementia risk. In our study, we investigated whether this effect is driven by specific mental work demands and whether it is exposure dependent. Methods Patients aged 75+ years were recruited from general practitioners and participated in up to seven assessment waves (every 1.5 years) of the longitudinal AgeCoDe study. Analyses of the impact of specific mental work demands on dementia risk were carried out via multivariate regression modeling (n = 2315). Results We observed a significantly lower dementia risk in individuals with a higher level of "information processing" (HR, 0.888), "pattern detection" (HR, 0.878), "mathematics" (HR, 0.878), and "creativity" (HR, 0.878). Yet, exposure-dependent effects were only significant for "information processing" and "pattern detection." Discussion Our longitudinal observations suggest that dementia risk may be reduced by some but not all types of mental work demands.

Objective To pilot-test feasibility, acceptance and learning-outcomes of a brief interdisciplinary communication skills training program in undergraduate medical education. Methods A two-hour interdisciplinary communication skills program with simulated patients was developed and pilot-tested with clinical students at Hamburg University. Five psychosocial specialties facilitated the training. Composite effects were measured qualitatively and quantitatively. Results Eighty students volunteered to participate in the pilot-program (intervention-group). Their evaluations of the program were very positive (1.1 on a six-point scale). Benefits were seen in feedback, increase of self-confidence, cross-disciplinary clinical and communication experience. Students who did not volunteer (n = 206) served as the control-group. The intervention-group performed significantly better (p = 0.023) in a primary care communication examination and female students performed better than males. Clinical teachers evaluated the pilot-training very positively with regard to learning-outcomes and feasibility. The positive results from the pilot-training led to implementation into the regular curriculum. Conclusions A two-hour interdisciplinary communication skills training program is beneficial for medical students with regard to communication competencies, self-confidence and learning-outcomes. Practice implication The training is feasible within given time-frames and limited staff resources. The high teaching load for small-group-training are split between five specialties. The concept might be an interesting option for other faculties.

Objective To develop learning objectives for a core communication curriculum for all health care professions and to survey the acceptability and suitability of the curriculum for undergraduate European health care education. Methods Learning objectives for a Health Professions Core Communication Curriculum (HPCCC) in undergraduate education were developed based on international literature and expert knowledge by an international group of communication experts representing different health care professions. A Delphi process technique was used to gather feedback and to provide a consensus from various health care disciplines within Europe. Results 121 communication experts from 15 professional fields and 16 European countries participated in the consensus process. The overall acceptance of the core communication curriculum was high. 61 core communication objectives were rated on a five-point scale and found to be relevant for undergraduate education in health care professions. A thematic analysis revealed the benefits of the HPCCC. Conclusions and practice implications Based on a broad European expert consensus, the Health Professions Core Communication Curriculum can be used as a guide for teaching communication inter- and multi-professionally in undergraduate education in health care. It can serve for curriculum development and support the goals of the Bologna process.

Background Depression is a risk factor for stroke and mortality but whether this also holds into old age is uncertain. We therefore studied the association of depression with the risk for non-fatal stroke and all-cause mortality in very old age. Methods A representative sample of 3085 primary care patients aged ≥75 years were serially assessed during a 6-year follow-up. The relation between depression (Geriatric Depression Scale >6, n=261) and relevant covariates including vascular risk factors and disease, functional and mild cognitive impairment and ApoE genotype on primary care givers information of incident stroke (n=209) and mortality (n=647) were assessed by Cox regression and by competing risk regressions. Results Depression was not independently associated with incident stroke in fully adjusted models that treated death as the competing event (subdistribution hazard ratio=0.80, 95% confidence interval=0.47 to 1.36). The risk associated with depression was similar for men and women, and for age groups 75–79, 80–84 and ≥85 years. In contrast, depression increased all-cause mortality rates, even after adjusting for a range of confounders (hazard ratio=1.31, 95% confidence interval=1.03 to 1.67). Limitations We have no information on past depressive episodes and cause of death. Conclusions In contrast to reports in younger populations, depression does not appear to increase stroke risk among the old and very old, but continuous to be a risk factor for all-cause mortality.

Objective To assess students’ communication skills during clinical medical education and at graduation. Methods We conducted an observational cohort study from 2007 to 2011 with 26 voluntary undergraduate medical students at Hamburg University based on video-taped consultations in year four and at graduation. 176 consultations were analyzed quantitatively with validated and non-validated context-independent communication observation instruments (interrater reliability ≥0.8). Based on observational protocols each consultation was also documented in free-text comments, salient topics were extracted afterwards. Results 26 students, seven males, were enrolled in the survey. On average, graduates scored higher in differential-diagnostic questioning and time management but showed deficiencies in taking systematic and complete symptom-oriented histories, in communication techniques, in structuring consultations and in gathering the patients’ perspectives. Patient-centeredness and empathy were rather low at graduation. Individual deficiencies could barely be eliminated. Conclusion Medical students were able to enhance their clinical reasoning skills and their time management. Still, various communication deficiencies in final year students became evident regarding appropriate history taking, communication skills, empathy and patient-centeredness. Practice implications The necessity of developing a longitudinal communication curriculum with enhanced communication trainings and assessments became evident. A curriculum should ensure that students’ communication competencies are firmly achieved at graduation.

Leicht H, Heinrich S, Heider D, Bachmann C, Bickel H, van den Bussche H, Fuchs A, Luppa M, Maier W, Mosch E, Pentzek M, Rieder-Heller SG, Tebarth F, Werle J, Weyerer S, Wiese B, Zimmermann T, Konig H-H, for the AgeCoDe study group. Net costs of dementia by disease stage. Objective: To estimate net costs of dementia by degree of severity from a societal perspective, including a detailed assessment of costs of formal and informal nursing care. Method: In a cross-sectional study, costs of illness were analysed in 176 dementia patients and 173 matched non-demented control subjects. Healthcare resource use and costs were assessed retrospectively by means of a questionnaire. Dementia patients were classified into three disease stages, and linear regression models were applied to estimate net costs of dementia by degree of severity. Results: Annual net costs of dementia by stage were approximately €15 000 (mild), €32 000 (moderate) and €42 000 (severe), corresponding to US-$21 450, 45 760 and 60 060 respectively. Across disease stages, nursing care accounted for approximately three-quarters of total costs, of which half resulted from informal care. In sensitivity analyses using different valuation methods for nursing care, total costs decreased or increased by more than 20%. Conclusion: Net costs more than double across stages of dementia. Informal care accounts for a considerable share of nursing care costs, and the approach to valuation of informal care has a large impact on cost-of-illness estimates.

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

Objective The prevailing opinion in the literature that disclosing the diagnosis of dementia to patients is important is not always put into practice. The purpose of this study was to investigate differences between GPs and specialists (neurologists and psychiatrists) in the German ambulatory care system concerning the disclosure of the diagnosis of dementia. Methods Thirty in depth interviews with randomly selected GPs were conducted. On this basis a standardised questionnaire was developed and sent to 389 GPs and 239 neurologists and psychiatrists. Results The postal survey revealed only minor differences between GPs and specialists, both groups being equally in favour of a timely disclosure. For example, 70% of the GPs and 77% of the specialists strongly agreed that “patients with dementia should be informed early because of the possibility to plan their lives”. This positive attitude is pronounced among younger physicians, but is somewhat contradicted by difficulties in the communication with patients expressed in the interviews. In the interviews, what may be described as a “double taboo” emerges, in that GPs describe taboo topic areas related to dementia for them and for their patients. Conclusion The postal survey shows the two professional groups to be very much in favour of a timely disclosure—an attitude that is pronounced among younger physicians. These findings can be interpreted as a recent change of attitudes regarding the disclosure of the diagnosis of dementia in the medical profession. Practice implications Training opportunities are needed in order to overcome communication obstacles in the doctor–patient-communication about dementia.

Objective Progression from cognitive impairment (CI) to dementia is predicted by several factors, but their relative importance and interaction are unclear. Method We investigated numerous such factors in the AgeCoDe study, a longitudinal study of general practice patients aged 75+. We used recursive partitioning analysis (RPA) to identify hierarchical patterns of baseline covariates that predicted dementia-free survival. Results Among 784 non-demented patients with CI, 157 (20.0%) developed dementia over a follow-up interval of 4.5 years. RPA showed that more severe cognitive compromise, revealed by a Mini-Mental State Examination (MMSE) score

Objective: to determine incidence and predictors of late-life depression. Methods: this is a 3-year observational cohort study of 3,214 non-demented patients aged 75 and over completing three waves of assessment. The patients were recruited in 138 primary care practices in six urban areas in Germany. Depressive symptoms were measured at baseline, and 18 months and 36 months later using the GDS-15 Geriatric Depression Scale with a cut-off 0–5/6–15. Cox proportional hazard regression models were applied to examine predictors of incident depression, adjusting for sex, age, education, living situation, activities of daily living - and instrumental activities of daily living impairment, somatic comorbidity, alcohol consumption, smoking, mild cognitive impairment and apoE4 status. Results: the incidence of depression was 36.8 (95% CI: 29.6–45.3) per 1,000 person-years in men and 46.0 (95% CI: 39.9–52.8) in women (sex difference P= 0.069). The incidence increased from 35.4 (95% CI: 29.7–41.9) per 1000 personyears between the ages of 75 and 79 to 75.2 (95% CI: 53.2–103.2) for subjects 85 years and older. After full adjustment for confounding variables, hazard ratios (HR) for incident depression were significantly higher for subjects 85 years and older (HR: 1.83, 95% CI: 1.24–2.70) and those with mobility impairment (HR: 2.53, 95% CI: 1.97–3.25), vision impairment (HR: 1.41, 95% CI: 1.04–1.91), mild cognitive impairment (HR: 1.52, 95% CI: 1.10–2.10), subjective memory impairment (HR: 1.33, 95% CI: 1.01–1.74) and current smoking (HR: 1.69, 95% CI: 1.13–2.53). Conclusions: the incidence of depression increased significantly with age. In designing prevention programmes, it is important to call more attention on functional impairment, cognitive impairment and smoking.

A variant within the clusterin gene has been recently associated with increased risk for Alzheimer's disease (AD) in genome wide association studies. Here we tested the association of the respective single nucleotide polymorphisms (rs11136000) with plasma concentration of clusterin in 67 AD subjects and 191 cognitively unimpaired elderly individuals. We observed an association of the rs11136000 AD-risk variant with low clusterin plasma levels in an allele-dose dependent manner in the healthy individuals (p = 0.011). This effect was numerically also present in the AD patients. We conclude that the rs11136000 AD-risk variant is associated with low clusterin plasma levels.

Background: Individuals with Mild Cognitive Impairment (MCI) are at high risk to develop dementia and are a target group for preventive interventions. Therefore, research aims at diagnosing MCI at an early stage with short, simple and easily administrable screening tests. Due to the fact that the Cl[for full text, please go to the a.m. URL], 10. Deutscher Kongress für Versorgungsforschung; 18. GAA-Jahrestagung

Depression among the elderly is an important public health issue. The aims of this study were to report the prevalence of depression and to determine the impact of socio-demographic variables, functional impairment and medical diagnoses, lifestyle factors, and mild cognitive impairment on depression as part of the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe Study).Included in the cross-sectional survey were 3327 non-demented subjects aged 75 and over attending general practitioners (GPs) (n=138) in an urban area of Germany. The GDS-15 Geriatric Depression Scale was used to measure depression with a threshold of6/6+. Associations with social and clinical risk factors were assessed by means of multiple logistic regression models.The prevalence of depression was 9.7% (95% confidence interval 8.7-10.7). In a univariate analysis, the following variables were significantly associated with depression: female gender, increasing age, living alone, divorce, lower educational status, functional impairment, comorbid somatic disorder, mild cognitive impairment, smoking, and abstinence from alcohol. After full adjustment for confounding variables, odds ratios for depression were significantly higher only for functional impairment, smoking, and multi-domain mild cognitive impairment.Recruitment procedures might have led to an underestimation of current prevalence. The cross-sectional data did not allow us to analyze the temporal relationship between risk factors and depression.The prevalence of depression in the elderly is high and remains high into old age. In designing prevention programs, it is important to call more attention to the impact of functional and cognitive impairment on depression.

Context Subjective memory impairment (SMI) is receiving increasing attention as a pre-mild cognitive impairment (MCI) condition in the course of the clinical manifestation of Alzheimer disease (AD). Objectives To determine the risk for conversion to any dementia, dementia in AD, or vascular dementia by SMI, graded by the level of SMI-related worry and by the temporal association of SMI and subsequent MCI. Design Longitudinal cohort study with follow-up examinations at 1½ and 3 years after baseline. Setting Primary care medical record registry sample. Participants A total of 2415 subjects without cognitive impairment 75 years or older in the German Study on Aging, Cognition and Dementia in Primary Care Patients. Main Outcome Measures Conversion to any dementia, dementia in AD, or vascular dementia at follow-up 1 or follow-up 2 predicted by SMI with or without worry at baseline and at follow-up 2 predicted by different courses of SMI at baseline and MCI at follow-up 1. Results In the first analysis, SMI with worry at baseline was associated with greatest risk for conversion to any dementia (hazard ratio [HR], 3.53; 95% confidence interval [CI], 2.07-6.03) or dementia in AD (6.54; 2.82-15.20) at follow-up 1 or follow-up 2. The sensitivity was 69.0% and the specificity was 74.3% conversion to dementia in AD. In the second analysis, SMI at baseline and MCI at follow-up 1 were associated with greatest risk for conversion to any dementia (odds ratio [OR], 8.92; 95% CI, 3.69-21.60) or dementia in AD (19.33; 5.29-70.81) at follow-up 2. Furthermore, SMI at baseline and amnestic MCI at follow-up 1 increased the risk for conversion to any dementia (OR, 29.24; 95% CI, 8.75-97.78) or dementia in AD (60.28; 12.23-297.10), with a sensitivity of 66.7% and a specificity of 98.3% for conversion to dementia in AD. Conclusion The prediction of dementia in AD by SMI with subsequent amnestic MCI supports the model of a consecutive 3-stage clinical manifestation of AD from SMI via MCI to dementia.