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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.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.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.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.

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.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.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.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.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.

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.

ObjectiveSince 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.MethodsLongitudinal 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.ResultsOur 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.ConclusionOur study stressed the longitudinal association between frailty and widowhood as well as chronic diseases and persistent frequent attendance among the oldest old in Germany.

Purpose Dealing with the high prevalence of pain among the oldest-old (+75) is becoming a major health issue. Therefore, the aim of the study was to uncover health-related lifestyle behaviors (HLB) and age-related comorbidities which may predict, influence and prevent pain in old age. Patients and methods In this longitudinal cohort study, data were obtained initially from 3.327 individuals aged 75+ from over 138 general practitioners (GP) during structured clinical interviews in 2003. Nine follow-ups (FU) were assessed until 2017. Available data from 736 individuals scoring in FU3 and FU7 were included in this analysis. Data were assembled in an ambulatory setting at participant's homes. Associations were tested using a linear regression model (model 1) and ordered logistic regression model (model 2). Results Statistical analyses revealed increased likelihood to experience pain for participants with comorbidities such as peripheral arterial disease (PAD) (coef. 13.51, P>t = 0.00) or chronic back pain (CBP) (coef. 6.64, P>t = 0.003) or higher body mass index (BMI) (coef. 0.57, P>t = 0.015) and, female gender (coef. 6.00, SE 3.0, t = 2.02, P>t = 0.044). Participants with medium education and former smokers showed significantly lower pain rating (coef. -5.05, P>t = 0.026; coef. -5.27, P>t = 0.026). Suffering from chronic back pain (OR = 2.03), osteoarthritis (OR = 1.49) or depressive symptoms (OR = 1.10) raised the odds to experience impairments in daily living due to pain. Physical activity showed no significant results. Conclusion Chronic conditions such as PAD, or CBP, female gender and higher BMI may increase the risk of experiencing more pain while successful smoking cessation can lower pain ratings at old age. Early and consistent support through GPs should be given to older patients in order to prevent pain at old age.

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 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 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.

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.

The article Driving status and health related quality of life among the oldest old: a population based examination using data from the AgeCoDe–AgeQualiDe prospective cohort study, written by André Hajek, Christian Brettschneider, Dagmar Lühmann, Hendrik van den Bussche, Birgitt Wiese, Silke Mamone, Siegfried Weyerer, Jochen Werle, Verena Leve, Angela Fuchs, Susanne Röhr, Janine Stein, Horst Bickel, Edelgard Mösch, Kathrin Heser, Michael Wagner, Martin Scherer, Wolfgang Maier, Steffi G. Riedel-Heller, Michael Pentzek and Hans-Helmut König was originally published electronically on the publisher’s internet portal (currently SpringerLink) on 11 rd January 2021 without open access. With the author(s)’ decision to opt for open choice, the copyright of the article changed on 1st July 2021 to © The Author(s) 2021 and the article is forthwith distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate whether changes were made.

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.

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.

To determine the prevalence of overweight and obesity, and to identify factors associated with obesity, among the oldest old.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.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.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.

There are very few studies examining the determinants of frequent attendance in primary care among the oldest old. The purpose of this study was to determine the characteristics of frequent attendance among individuals aged 85 years or older. 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. 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). 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. 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.

Background and Objectives We examined the validity of 5 successful aging (SA) operationalizations that assessed different facets of the SA construct (cognitive and physical health and disability; well-being; social engagement). Research Design and Methods A total of 2,478 participants (mean age = 82.5 years, standard deviation [SD] = 3.47) were studied. We used confirmatory factor analysis to investigate the relationships between facets and to determine the convergent validity as well as short-term (1.5 years) and long-term (4.5 years) predictive validity of the 5 SA operationalizations for measures of quality of life (QoL) and objective health outcomes. Results A general SA operationalization that included all SA facets but also allowed differences between them showed the best model fit and construct validity. A biomedical operationalization of SA that excluded either the well-being or the social engagement facet showed lower convergent and predictive validity for subjective measures (e.g., QoL) but higher associations with objective measures (e.g., health). A purely psychosocial SA operationalization that excluded the physiological facet did not allow good prediction of objective health outcomes. Discussion and Implications Our results suggest that a well-balanced SA operationalization should include measures assessing health, disability, well-being, and social engagement.

Aim To present data on the prevalence of driving habits and to identify the determinants of driving habits among the oldest old in Germany. Methods Cross-sectional data were used 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), including primary care patients aged 85 years and above (n = 549 at FU 9, mean age was 90.3 years; 86–101 years). Driving habits were measured (driving a car; frequency of driving a car and driving duration). Correlates were quantified using widely established scales (e.g., Geriatric Depression Scale, Instrumental Activities of Daily Living Scale). Multiple regression models were used to identify the determinants of driving habits. Results Sixteen percent (87 out of 549) drove a car. Among the car-drivers, about 80% drove at least several times a week and about two-thirds drove longer distances (>15 min). Multiple logistic regressions showed that among the oldest old being a male was more likely to be a current driver compared to being a female. Other significant factors were subjective memory impairment, severe visual impairment, functional and cognitive impairment. Correlates of frequency of driving a car and driving duration were further identified. Conclusion About one in six very old Germans is still a regular car driver. Several determinants of driving habits among the oldest old were identified. Future longitudinal studies are required to clarify the factors leading to changes in driving habits.

OBJECTIVE To analyze the association of anxiety symptoms with health care use and costs in people aged 85 and older. METHODS Baseline data from AgeQualiDe (N = 856), a multicenter prospective cohort study of primary care patients aged 85 and older, were analyzed. Anxiety symptoms (Geriatric Anxiety Inventory-Short Form) and health care use were assessed via questionnaires. Health care use was monetarily valued using German unit costs to obtain sectoral (inpatient, outpatient, nursing care, medical supplies, and medication) and total costs. Health care use and costs were analyzed in regression models as a function of anxiety symptoms, as well as relevant covariates (predisposing, enabling, and other need characteristics based on the Behavioral Model of Health Care Use). RESULTS On a descriptive level, people with increased anxiety symptoms (12% of the sample) incurred on average € 10 909 (SD: 16 023) in the last 6 months, 31% more than those without increased anxiety (€ 8303, SD: 11 175; P = 0.12). Adjusting for predisposing, enabling, and other need characteristics, anxiety symptoms were not significantly associated with health care use or costs. Specifically, need characteristics (morbidity, cognitive decline, and functional impairment) were associated with total or sectoral costs, depending on the cost category analyzed. CONCLUSION In a sample of people of the oldest-old age group, the severity of anxiety symptoms was not associated with health care use or costs, when adjusting for relevant covariates. A longitudinal analysis could assess whether a change in anxiety symptom severity is associated with health care use or costs in old age.

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.

Ziel der Studie: Uber die Einflussfaktoren der Pflegebedurftigkeit alter Menschen ist im Langsschnitt bisher wenig bekannt. Die Kenntnis dieser Faktoren ist allerdings wichtig, um Ansatzpunkte fur die Vermeidung oder Hinauszogerung von Pflegebedurftigkeit im Alter zu identifizieren. Ziel ist es, Einflussgrosen der Pflegebedurftigkeit alter Menschen im Langsschnitt zu analysieren. Methodik: Es wurden Daten aus 4 Wellen im Abstand von je 1,5 Jahren einer bevolkerungsbasierten prospektiven Kohortenstudie (AgeCoDe) verwendet, in der die Teilnehmer zur Baseline (n=3 217) mindestens 75 Jahre alt waren. Die Pflegebedurftigkeit wurde gemas § 15 SGB XI uber die Pflegestufe operationalisiert. Dabei wurden die potentiellen Pradiktoren der Pflegebedurftigkeit (soziodemografische Variablen, Beeintrachtigungen im Gehen/Sehen/Horen, Demenz und Depression) im Langsschnitt mithilfe von Random-Effects-Logit-Modellen untersucht. Ergebnisse: Die Regressionsanalysen im Langsschnitt zeigten, dass das Auftreten einer Demenz (OR: 48,2) oder von Beeintrachtigungen im Gehen (erschwertes Gehen, OR: 26,4; Gehunfahigkeit, OR: 747,9) sowie der Alterungsprozess (z. B. 90 Jahre und alter vs. Schlussfolgerung: Mogliche Ansatzpunkte fur die Vermeidung oder Hinauszogerung von Pflegebedurftigkeit im Alter liegen insbesondere im Bereich der Erhaltung der Gehfahigkeit und der kognitiven Leistung. Angesichts des demografischen Wandels ist die Entwicklung von entsprechenden Programmen zur Vermeidung von Pflegebedurftigkeit im Alter von groser gesundheitspolitischer Bedeutung.

The aim of this study was to identify determinants of outpatient health care utilization among the oldest old in Germany longitudinally. 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). Individuals in very old age were recruited via GP offices at six study centers in Germany. The course of outpatient health care was observed over 10 months (two waves). Primary care patients aged 85 years and over (at baseline: n=861, with mean age of 89.0 years±2.9 years; 85–100 years). Self-reported numbers of outpatient visits to general practitioners (GP) and specialists in the past three months were used as dependent variables. Widely used scales were used to quantify explanatory variables (e.g., Geriatric Depression Scale, Instrumental Activities of Daily Living Scale, or Global Deterioration Scale). Fixed effects regressions showed that increases in GP visits were associated with increases in cognitive impairment, whereas they were not associated with changes in marital status, functional decline, increasing number of chronic conditions, increasing age, and changes in social network. Increases in specialist visits were not associated with changes in the explanatory variables. Our findings underline the importance of cognitive impairment for GP visits. Creating strategies to postpone cognitive decline might be beneficial for the health care system.

Background Potentially inappropriate medication (PIM) is associated with an increased risk for detrimental health outcomes in elderly patients. Some antidepressant drugs are considered as PIM, but previous research on the association between antidepressants and subsequent dementia has been inconclusive. Therefore, we investigated whether the intake of antidepressants, particularly of those considered as PIM according to the Priscus list, would predict incident dementia. Methods We used data of a prospective cohort study of non-demented primary care patients (n = 3239, mean age = 79.62) to compute Cox proportional hazards models. The risk for subsequent dementia was estimated over eight follow-ups up to 12 years depending on antidepressant intake and covariates. Results The intake of antidepressants was associated with an increased risk for subsequent dementia (HR = 1.53, 95% CI: 1.16–2.02, p = .003; age-, sex-, education-adjusted). PIM antidepressants (HR = 1.49, 95% CI: 1.06–2.10, p = .021), but not other antidepressants (HR = 1.04, 95% CI: 0.66–1.66, p = .863), were associated with an increased risk for subsequent dementia (in age-, sex-, education-, and depressive symptoms adjusted models). Significant associations disappeared after global cognition at baseline was controlled for. Limitations Methodological limitations such as selection biases and self-reported drug assessments might have influenced the results. Conclusions Only antidepressants considered as PIM were associated with an increased subsequent dementia risk. Anticholinergic effects might explain this relationship. The association disappeared after the statistical control for global cognition at baseline. Nonetheless, physicians should avoid the prescription of PIM antidepressants in elderly patients whenever possible.

To investigate time-dependent predictors of frailty in old age longitudinally. Population-based prospective cohort study. Elderly individuals were recruited via GP offices at six study centers in Germany. The course of frailty was observed over 1.5 years (follow up wave 4 and follow up wave 5). 1,602 individuals aged 80 years and older (mean age 85.4 years SD 3.2, with mean CSHA CFS 3.5 SD 1.6) at follow up wave 4. Frailty was assessed by using the Canadian Study of Health and Aging Clinical Frailty Scale (CSHA CFS), ranging from 1 (very fit) to 7 (severely frail). Fixed effects regressions revealed that frailty increased significantly with increasing age (s=.2) as well as the occurrence of depression (s=.5) and dementia (s=.8) in the total sample. Changes in marital status and comorbidity did not affect frailty. While the effects of depression and dementia were significant in women, these effects did not achieve statistical significance in men. Our findings highlight the role of aging as well as the occurrence of dementia and depression for frailty. Specifically, in order to delay frailty in old age, developing interventional strategies to prevent depression might be a fruitful approach.

The aim of the study was to investigate the psychometric properties of a Short Form of the Mini-Mental State Examination (SMMSE) for the screening of dementia in older primary care patients. Data were obtained from a large longitudinal cohort study of initially nondemented individuals recruited via primary care chart registries and followed at 18-month intervals. Item and scale parameters for MMSE and SMMSE scores were analyzed and cross-validated for 2 follow-up assessments (n1 = 2,657 and n2 = 2,274). Binary logistic regression and receiver-operating-characteristic (ROC) curve analyses were conducted in order to assess diagnostic accuracy parameters for MMSE and SMMSE scores. Cross-sectional differentiation between dementia-free and dementia patients yielded moderate to good results for MMSE and SMMSE scores. With regard to most diagnostic accuracy parameters, SMMSE scores did not outperform the MMSE scores. The current study provides first evidence regarding the psychometric properties of the SMMSE score in a sample of older primary care patients. However, our findings do not confirm previous findings that the SMMSE is a more accurate screening instrument for dementia than the original MMSE. Further studies are needed in order to assess and to develop short, reliable and valid instruments for routine cognitive screening in clinical practice and primary care settings.

Objective The purpose of this study was to examine the impact of falls on depressive symptoms among the oldest old in Germany longitudinally. Methods Data were used from 2 waves of 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 primary care patients ≥85 years (at baseline: n = 547, average age of 88.9 ± 3.0 years; ranging from 85 to 100 years). General practitioner-diagnosed falls were used as explanatory variable. The Geriatric Depression Scale was used as outcome measure. Results Linear fixed effects regressions showed that the occurrence of falls is associated with an increase in depressive symptoms (β = .60, P = .02), whereas changes in marital status, ageing, social support, functional decline (instrumental activity of daily living), cognitive impairment, and an increase in chronic diseases did not affect depressive symptoms. In sensitivity analysis, an increase in depressive symptoms was associated with functional impairment (basic activities of daily living; Barthel index; β = -.04, P = .005). Conclusions Based on a large, population-based longitudinal study, this study underlined the impact of falls on depressive symptoms and consequently extended previous knowledge about an association between falls and depressive symptoms in the oldest old. Developing strategies to prevent falls might also help to prevent depressive symptoms.

To investigate causal factors of functional impairment in old age in a longitudinal approach. A population-based prospective cohort study. Elderly individuals were recruited via GP offices at six study centers in Germany. They were observed every 1.5 years over six waves. Three thousand two hundred fifty-six people aged 75 years and older at baseline. Functional impairment was quantified by the Lawton and Brody Instrumental Activities of Daily Living scale (IADL) and the Barthel-Index (BI). Fixed effects regressions revealed that functional impairment (IADL; BI) increased significantly with ageing (β=-.2; β=-1.1), loss of a spouse (β=.5; β=-3.1), not living alone in private household (β=-1.2; β=-5.5), depression (solely significant for IADL: β=.6) and dementia (β=-2.3; β=-18.2). The comorbidity score did not affect functional impairment. Our findings underline the relevance of changes in sociodemographic variables as well as the occurrence of depression or dementia for functional impairment. While several of these causal factors for functional decline in the oldest old are inevitable, some may not be, such as depression. Therefore, developing interventional strategies to prevent depression might be a fruitful approach in order to delay functional impairment in old age.

Background:Most of the previous studies attempted to disentangle the relationship between disability and depressive symptoms were limited to observation periods of only few years. Moreover, evidence is missing regarding the complex co-occurrence of disability and depressive symptoms in old age in Germany. In order to close the research gap, we aimed at disentangling the complex co-occurrence of disability and depressive symptoms in old age in Germany over a longer time frame.Methods:Based on data from a representative survey of the German general population aged 75 years and older, the course of disability as well as depressive symptoms was observed every 1.5 years over six waves. While disability was quantified by the Lawton and Brody Instrumental Activities of Daily Living scale, the Geriatric Depression Scale was used to measure depressive symptoms. Taking into account the complex co-occurrence of depressive symptoms and disability, a panel vector autoregressive model was used. By taking the first differences, unobserved heterogeneity was taken into account.Results:In the total sample and in both sexes, we revealed a robust positive association between an initial change in depressive symptoms and subsequent changes in disability. No robust association between an initial change in disability and a subsequent change in depressive symptoms was detected.Conclusion:Our findings highlight the importance of changes in depressive symptoms for future changes in disability in old age.

Background: In the future, an increase in health care needs in the elderly is expected. Reports on unmet care needs of the oldest old with cognitive disorders are pending. This study aims at exploring unmet needs in the oldest old primary care patients with mild cognitive impairment (MCI) and dementia. Furthermore, the association between sociodemographic and clinical factors and unmet needs ought to be analyzed. Methods: Based on the study “Needs, Health Service Use, Costs and Health-Related Quality of Life in a Large Sample of Oldest-Old Primary Care Patients (85+)” (AgeQualiDe), 749 patients (unimpaired, MCI, and dementia) aged 85 years and older, their relatives (n = 421), and general practitioners (GPs) (n = 607) were assessed. Descriptive, inferential, and regression analyses were run. Results: Most unmet needs were observed in dementia patients, although needs were less frequently rated as unmet by dementia patients themselves as compared to relatives and GPs. Unmet needs were associated with MCI and dementia; other risk factors were age, education, and marital status. Conclusion: This study provides first data on unmet needs according to different perceptions in the elderly with MCI and dementia in Germany. Need assessments should be part of medical examinations to ensure a high-quality health care in the elderly.

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.

Background Elderly people are often burdened by several diseases. This accounts for a higher medication intake and increases the risk of adverse drug events. To minimize this risk, several lists (Beers, PRISCUS) have been published of drugs that elderly patients should not take. We present a longitudinal analysis of the use of potentially inappropriate medication (PIM) over a period 4.5 years in a cohort of patients aged 75 years or more. Methods Data were collected from the prospective, multicenter, observational study "German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe)," initially enrolling 3,327 patients. We investigated the prevalence of PIM by checking medications during visits to patients' homes. Furthermore, we analyzed the use of individual PIM agents over time. Results At baseline, we found a PIM prevalence of 29 % according to the PRISCUS list, which decreased to 25.0 % 4.5 years later (χ(2): 7.87, p = 0.004). The Beers list yielded a prevalence of 21 % at baseline, decreasing after 4.5 years to 17.1 % (χ(2): 10.77, p = 0.000). A time-dependent multilevel model confirmed these results. Older age, depression, and the use of numerous prescribed agents are independent risk factors for using a PRISCUS-PIM. Conclusion Our results seem to support a trend toward a more rational drug therapy because fewer patients were prescribed PIM. Thus, for the individual patient, the risk of adverse effects and side effects is reduced as are the costs of these effects.

Background It is unknown whether longitudinal stability versus instability in subjective cognitive decline (SCD) is a modifying factor of the association between SCD and risk of incident Alzheimer's disease (AD) dementia. Objective We tested the modifying role of temporal stability of the SCD report on AD dementia risk in cognitively normal elderly individuals. Methods We analyzed data of 1,990 cognitively normal participants from the longitudinal AgeCoDe Study. We assessed SCD with/without associated worries both at baseline and first follow-up 18 months later. Participants were then classified either as (a) Controls (CO, with no SCD at both baseline and follow-up 1, n = 613), (b) inconsistent SCD (with SCD reported only at baseline or at follow-up 1, n = 637), (c) consistent SCD but without/or with inconsistent worries (n = 610) or (d) consistent SCD with worries (n = 130). We estimated incident AD dementia risk over up to 6 years for each group with Cox-Proportional Hazard Regression analyses adjusted for age, gender, education, ApoE4 status, and depression. Results Compared to CO, inconsistent SCD was not associated with increased risk of incident AD dementia. In contrast, risk was doubled in the group of consistent SCD without/ with inconsistent worries, and almost 4-fold in the group of consistent SCD with worries. These results could be replicated when using follow-up 1 to follow-up 2 response patterns for group definition. Conclusion These findings suggest that longitudinal stability versus instability is an important modifying factor of the association between SCD and AD dementia risk. Worrisome SCD that is also consistently reported over time is associated with greatly increased risk of AD dementia.

Stein J, Luppa M, Maier W, Wagner M, Wolfsgruber S, Scherer M, Kohler M, Eisele M, Weyerer S, Werle J, Bickel H, Mosch E, Wiese B, Prokein J, Pentzek M, Fuchs A, Leicht H, Konig H-H, Riedel-Heller SG for the AgeCoDe Study Group. Assessing cognitive changes in the elderly: Reliable Change Indices for the Mini-Mental State Examination. Objective: The diagnosis of dementia includes evidence of decline in cognitive functioning over time measured by objective cognitive tasks. Normative data for changes adjusted for the impact of socio-demographic factors on cognitive test performance are lacking to interpret changes in Mini-Mental State Examination (MMSE) test scores. Method: As part of the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe Study), a sample of 1090 cognitively healthy individuals, aged 75 years and older, was assessed at 1.5-year intervals over a period of 4.5 years using the MMSE. Age- and education-specific Reliable Change Indices (RCIs) were computed. Results: Age and education were significantly associated with MMSE test performance, and gender indicated no impact. Across different age and education subgroups, changes from at least 2 up to 3 points indicated significant (i.e., reliable) changes in MMSE test scores at the 90% confidence level. Furthermore, the calculation of RCIs for individual patients is demonstrated. Conclusion: This study provides age- and education-specific MMSE norms based upon RCI methods to interpret cognitive changes in older age groups. The computation of RCI scores improves the interpretation of changes in MMSE test scores by controlling for measurement error, practice effects, or regression to the mean.

Background/Aims: The diagnostic criteria for dementia include reliable evidence of cognitive deterioration over time measured by cognitive tests. The Structured Interview for the Diagnosis of Dementia of the Alzheimer Type, Multi-infarct Dementia and Dementia of other Etiology according to DSM-III-R, DSM-IV and ICD-10 (SIDAM) is a neuropsychological instrument to determine cognitive status in patients with mild cognitive impairment (MCI) and dementia. Normative data for changes in cognitive functioning that normally occur in cognitively healthy individuals are required to interpret changes in SIDAM test scores. Methods: A sample of 1,090 cognitively healthy individuals participating in the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe) aged 75 years and older was assessed four times at 1.5-year intervals over a period of 4.5 years using the SIDAM. Age- and education-specific reliable change indices (RCIs) accounting for probable measurement error and practice effects were computed for a 90% confidence interval. Results: Across different age and education subgroups, changes from at least 3–5 points indicated significant (i.e. reliable) changes in SIDAM test scores at the 90% confidence level. Conclusion: This study offers age- and education-specific normative data for the SIDAM based upon established RCI methods. The RCI scores provided in this study may help clinicians and researchers to interpret cognitive changes in SIDAM test scores and may contribute to the early detection and diagnosis of MCI and dementia in the elderly.

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.

In the last decades, many community-based studies have addressed predictors of nursing home placement (NHP) among the elderly. So far, predictors have not been analyzed separately for different age groups. For a German GP-sample of 3,208 subjects aged 75 years and older, socio-demographic, clinical, and psychometric parameters were requested every 1.5 years over three waves. Logistic regression models determined predictors of NHP for total sample and for two different age groups. A CART analysis identified factors discriminating best between institutionalized and non-institutionalized individuals. Of the overall sample, 4.7% of the sample (n = 150) was institutionalized during the study period. Baseline characteristics associated with a higher risk of NHP for the total sample were age, living without spouse, cognitive and functional impairment and depression. In the CART analysis, age was the major discriminator at the first level (at age 81). In subgroup regression analyses, for the younger elderly (age 75–81) being single as well as cognitive and functional impairment increased the risk of NHP; in the advanced elderly (age 82+) being widowed and subjective memory impairment were significant predictors for NHP, and cognitive and functional impairment became non-significant as predictors of NHP. Predictors of NHP may differ in old age groups. The fact that many predictors show inconsistent results as predictors of NHP in the international literature may be attributed to the lack of differentiation in age groups.

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.

General practitioners (GP) play an important role in detecting cognitive impairment among their patients.To explore factors associated with GPs' judgment of their elderly patients' cognitive status.Cross-sectional data from an observational cohort study (AgeCoDe study); General practice surgeries in six German metropolitan study centers; home visits by interviewers.138 GPs, 3,181 patients (80.13 +/- 3.61 years, 65.23% female).General practitioner questionnaire for each patient: familiarity with the patient, patient morbidity, judgment of cognitive status. Home visits by trained interviewers: sociodemographic and clinical data, psychometric test performance. Multivariate regression analysis was used to identify independent associations with the GPs' judgment of "cognitively impaired" vs. "cognitively unimpaired."Less familiar patients (adjusted odds ratio [aOR] 2.42, 95% CI 1.35-4.32, for poor vs. very high familiarity), less mobile patients (aOR 1.29, 95% CI 1.13-1.46), patients with impaired hearing (aOR 5.46, 95% CI 2.35-12.67 for serious vs. no problems), and patients with greater comorbidity (aOR 1.15, 95% CI 1.08-1.22) were more likely to be rated as "cognitively impaired" by their GPs.The associations between GPs' assessments of cognitive impairment and their familiarity with their patients and patients' mobility, hearing, and morbidity provide important insights into how GPs make their judgments.

Mit der CERAD-NP-Testbatterie liegen gut etablierte Verfahren zur neuropsychologischen Diagnostik charakteristischer kognitiver Defizite einer Demenz vom Alzheimer-Typ vor. Die Anwendbarkeit neuropsychologischer Verfahren setzt das Vorhandensein zuverlassiger Normwerte fur die zugrunde liegende Population unter Berucksichtigung soziodemographischer Faktoren wie Alter, Bildung und Geschlecht voraus. In der vorliegenden Arbeit wurden alters- bildungs- und geschlechtsspezifische Normwerte (Prozentrange und T-Werte bzw. Perzentile) fur die Subtests Verbale Flussigkeit, Wortliste Gedachtnis, Wortliste Abrufen und Wortliste Wiedererkennen sowie den Wortliste-Savings-Score der CERAD-NP-Testbatterie an einer Stichprobe von 2891 alteren (75 Jahre und daruber) nichtdementen Hausarztpatienten aus Deutschland ermittelt. Die Probanden hatten ein Durchschnittsalter von 80,2 Jahren (SD=3,6); somit bietet dieser Beitrag zuverlassige Normwerte fur die neuropsychologische Demenzdiagnostik in den hoheren Altersgruppen an.

SUMMARY Background Little is known about the prevalence and risk factors of alcohol problems among older people (especially those aged 75 years and more). The aims of this study were to report alcohol consumption patterns and to determine their association with socio-demographic variables and health characteristics. Method 3224 non-demented subjects aged 75 and over and attending general practitioners (GPs) (n ¼ 138) in an urban area of Germany were studied by structured clinical interviews including detailed assessment of alcohol consumption patterns distinguishing between abstainers, moderate drinkers and at-risk drinkers (>20 g of alcohol for women and >30 g of alcohol for men). Results A high proportion (50.1%) of the sample were abstainers, 43.4% were moderate drinkers. The prevalence of at-risk alcohol consumption was 6.5% (95% CI 5.6–7.4). Rates were significantly higher for men (12.1%; 95% CI 10.2–14.0) compared to women (3.6%; 95% CI 2.8–4.4). After full adjustment for confounding variables we found that compared to moderate drinking abstaining from alcohol was significantly associated with female gender, lower education, and mobility impairment. Compared to moderate drinking at-risk drinking was significantly higher among men, individuals with a liver disease, and current smokers. Conclusions Multivariate analysis revealed that, apart from liver disease, at-risk drinking in a non-demented population aged 75 and over was associated with relatively good physical and mental health. Nevertheless, public prevention measures should focus on at-risk drinkers to make them aware of potential risks of high alcohol consumption in old age. Copyright # 2009 John Wiley & Sons, Ltd.

OBJECTIVE: The suitability of the SIDAM (Structured Interview for the Diagnosis of Dementia) for the detection of pre-clinical stages of dementia. METHODS: Prospective study of a sample of 794 non-demented elderly persons in the age bracket from 65 to 85 who were initially being treated in general hospitals. A cognitive screening with the SIDAM was performed during their stay in the hospital. After discharge the occurrence of dementia was determined in four follow-up studies at one-year intervals. RESULTS: During the follow-up, 100 newly developed cases of dementia were diagnosed. A lower performance in the SIDAM was associated with a significantly higher risk of the development of dementia. In comparison with the upper quartile in total SIDAM score the relative risk of a dementia amounted to 2.6 (1.0-6.8) for the second quartile, 4.5 (1.9-11.0) for the third quartile and 13.3 (5.7-31.1) for the fourth quartile. The highest predictive validity was found for memory performance, in particular for free delayed recall. CONCLUSIONS: Risk groups for dementia can be identified by the use of a brief cognitive screening procedure.