[Show abstract][Hide abstract] ABSTRACT: Background: Depression belongs to the most common mental disorders in late life and will lead to a significant increase of treatment and health care needs in the future. The Camberwell Assessment of Need for the Elderly (CANE) evaluates met and unmet care needs in older individuals. Reports on needs of the elderly with depression are currently lacking. The aim of the present study was to identify met and unmet needs in older primary care patients with and without depression using the German-language version of the CANE. Furthermore, the association between unmet needs and depression ought to be explored. Methods: As part of the study “Late-life depression in primary care: needs, health care utilization and costs (AgeMooDe)”, a sample of 1,179 primary care patients aged 75 years and older was assessed. Descriptive and inferential statistics as well as logistic regression analyses were conducted. Results: This study, for the first time in Germany, provides data on the distribution of met and unmet needs in depressive and non-depressive older primary care patients. As a main result, unmet needs were significantly associated with depression; other risk factors identified were gender, institutionalization, care by relatives and impaired functional status. Limitations: The conclusions about directions and causality of associations between the variables are limited due to the cross-sectional design. Conclusions: The study results provide an important contribution to generate a solid base for an effective and good-quality health and social care as well as to an appropriate allocation of health care resources in the elderly population.
Full-text · Article · Jan 2016 · Journal of Affective Disorders
[Show abstract][Hide abstract] ABSTRACT: Background In older patients with chronic diseases, focusing on subjective, patient-relevant outcomes, such as health-related quality of life (HRQoL), is more pertinent than pursuing clinical or laboratory target values.Aim To investigate factors influencing the course of HRQoL in older (aged ≥78 years) primary care patients and to derive non-pharmacological recommendations for improving their quality of life.Design and setting A population-based prospective longitudinal observational study featuring data analysis from waves 2 to 5 of the AgeCoDe study, which was conducted in six cities in Germany.Method The HRQoL of 1968 patients over the course of 4.5 years was observed. Patients were, on average, aged 82.6 (±3.4) years and their HRQoL was measured using the EQ-5D visual analogue scale in a face-to-face assessment. Fixed-effects regression models were calculated to examine impact of change in potential influencing factors. This method allows unobserved heterogeneity to be controlled.Results The cours
No preview · Article · Oct 2015 · British Journal of General Practice
[Show abstract][Hide abstract] ABSTRACT: Human episodic memory performance is linked to the function of specific brain regions, including the hippocampus; declines as a result of increasing age; and is markedly disturbed in Alzheimer disease (AD), an age-associated neurodegenerative disorder that primarily affects the hippocampus. Exploring the molecular underpinnings of human episodic memory is key to the understanding of hippocampus-dependent cognitive physiology and pathophysiology.
To determine whether biologically defined groups of genes are enriched in episodic memory performance across age, memory encoding-related brain activity, and AD.
In this multicenter collaborative study, which began in August 2008 and is ongoing, gene set enrichment analysis was done by using primary and meta-analysis data from 57 968 participants. The Swiss cohorts consisted of 3043 healthy young adults assessed for episodic memory performance. In a subgroup (n = 1119) of one of these cohorts, functional magnetic resonance imaging was used to identify gene set-dependent differences in brain activity related to episodic memory. The German Study on Aging, Cognition, and Dementia in Primary Care Patients cohort consisted of 763 elderly participants without dementia who were assessed for episodic memory performance. The International Genomics of Alzheimer's Project case-control sample consisted of 54 162 participants (17 008 patients with sporadic AD and 37 154 control participants). Analyses were conducted between January 2014 and June 2015. Gene set enrichment analysis in all samples was done using genome-wide single-nucleotide polymorphism data.
Episodic memory performance in the Swiss cohort and German Study on Aging, Cognition, and Dementia in Primary Care Patients cohort was quantified by picture and verbal delayed free recall tasks. In the functional magnetic resonance imaging experiment, activation of the hippocampus during encoding of pictures served as the phenotype of interest. In the International Genomics of Alzheimer's Project sample, diagnosis of sporadic AD served as the phenotype of interest.
In the discovery sample, we detected significant enrichment for genes constituting the calcium signaling pathway, especially those related to the elevation of cytosolic calcium (P = 2 × 10-4). This enrichment was replicated in 2 additional samples of healthy young individuals (P = .02 and .04, respectively) and a sample of healthy elderly participants (P = .004). Hippocampal activation (P = 4 × 10-4) and the risk for sporadic AD (P = .01) were also significantly enriched for genes related to the elevation of cytosolic calcium.
By detecting consistent significant enrichment in independent cohorts of young and elderly participants, this study identified that calcium signaling plays a central role in hippocampus-dependent human memory processes in cognitive health and disease, contributing to the understanding and potential treatment of hippocampus-dependent cognitive pathology.
[Show abstract][Hide abstract] ABSTRACT: 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. (PsycINFO Database Record
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No preview · Article · Mar 2015 · Psychological Assessment
[Show abstract][Hide abstract] ABSTRACT: Multimorbidity is highly prevalent in the elderly and relates to many adverse outcomes, such as higher mortality, increased disability and functional decline. Many studies tried to reduce the heterogeneity of multimorbidity by identifying multimorbidity clusters or disease combinations, however, the internal structure of multimorbidity clusters and the linking between disease combinations and clusters are still unknown. The aim of this study was to depict which diseases were associated with each other on person-level within the clusters and which ones were responsible for overlapping multimorbidity clusters.
The study analyses insurance claims data of the Gmunder ErsatzKasse from 2006 with 43,632 female and 54,987 male patients who were 65 years and older. The analyses are based on multimorbidity clusters from a previous study and combinations of three diseases ("triads") identified by observed/expected ratios >= 2 and prevalence rates >= 1%. In order to visualise a "disease network", an edgelist was extracted from these triads, which was analysed by network analysis and graphically linked to multimorbidity clusters.
We found 57 relevant triads consisting of 31 chronic conditions with 200 disease associations ("edges") in females and 51 triads of 29 diseases with 174 edges in males. In the disease network, the cluster of cardiovascular and metabolic disorders comprised 12 of these conditions in females and 14 in males. The cluster of anxiety, depression, somatoform disorders, and pain consisted of 15 conditions in females and 12 in males.
We were able to show which diseases were associated with each other in our data set, to which clusters the diseases were assigned, and which diseases were responsible for overlapping clusters. The disease with the highest number of associations, and the most important mediator between diseases, was chronic low back pain. In females, depression was also associated with many other diseases. We found a multitude of associations between disorders of the metabolic syndrome of which hypertension was the most central disease. The most prominent bridges were between the metabolic syndrome and musculoskeletal disorders. Guideline developers might find our approach useful as a basis for discussing which comorbidity should be addressed.
Full-text · Article · Dec 2014 · BMC Public Health
[Show abstract][Hide abstract] ABSTRACT: Type 2 diabetes mellitus (T2DM) is a risk factor of dementia. The effect of T2DM treatment quality on dementia risk, however, is unclear. 1,342 elderly individuals recruited via general practitioner registries (AgeCoDe cohort) were analyzed. This study analyzed the association between HbA1c level and the incidence of all-cause dementia (ACD) and of Alzheimer's disease dementia (referred to here as AD). HbA1c levels ≥6.5% were associated with 2.8-fold increased risk of incident ACD (p = 0.027) and for AD (p = 0.047). HbA1c levels ≥7% were associated with a five-fold increased risk of incident ACD (p = 0.001) and 4.7-fold increased risk of incident AD (p = 0.004). The T2DM diagnosis per se did not increase the risk of either ACD or AD. Higher levels of HbA1c are associated with increased risk of ACD and AD in an elderly population. T2DM diagnosis was not associated with increased risk if HbA1c levels were below 7%.
No preview · Article · Dec 2014 · Journal of Alzheimer's disease: JAD
[Show abstract][Hide abstract] ABSTRACT: Hintergrund
Für Hausärzte ist die Betreuung von Patienten mit Multimorbidität eine alltägliche Herausforderung. Leitlinien, die jeweils nur einzelne Erkrankungen im Fokus haben, können hier nicht umfassend und „gleichberechtigt“ Anwendung finden. Stattdessen müssen Prioritäten gesetzt werden.
Vor diesem Hintergrund wird herausgearbeitet, wie Hausärzte und ihre Patienten diesen Herausforderungen begegnen und welche Prioritäten sie jeweils setzen.
Material und Methoden
Neun Hausärzte und 19 ihrer Patienten mit Multimorbidität wurden narrativ interviewt. Die Analyse erfolgte inhaltsanalytisch.
Die Mehrzahl der interviewten Patienten fühlte sich durch ihren Hausarzt gut oder sehr gut betreut. Dennoch stellten sich die Prioritäten der Hausärzte und die ihrer Patienten häufig unterschiedlich dar. Während die Ärzte die meiste Energie auf das Management von Erkrankungen verwendeten, die zu potenziell lebensbedrohlichen Situationen führen können, stand bei den Patienten der unmittelbare Erhalt von Autonomie und sozialem Miteinander im Vordergrund.
Die Ergebnisse der Studie legen den Schluss nahe, dass die Kommunikation zwischen Hausärzten und ihren Patienten gerade in Bezug auf einen gemeinsamen Prozess der Prioritätensetzung bei Multimorbidität weiterentwickelt werden kann.
No preview · Article · Oct 2014 · Zeitschrift für Gerontologie + Geriatrie
[Show abstract][Hide abstract] ABSTRACT: Background:
Dementia is a main reason for nursing home admission. Information on institutionalization is often based on studies of limited methodological quality. We aimed to analyze time until nursing home admission since first coding of dementia diagnosis and factors associated with institutionalization in incident dementia patients compared to non-demented controls.
We analyzed claims data of a German Health insurance company including a cohort of 1,440 patients with a first diagnosis of dementia and 6,988 age- and sex-matched controls aged 65 years and older. The follow-up was up to 5 years. We used Kaplan-Meier analysis for examining time until nursing home admission and cox regression for estimating crude and adjusted Hazard ratios.
Dementia patients and controls were on average 78 years and about 55 % were males. The mean time to nursing home admission was 4.0 years in patients with dementia and 4.6 years for controls. After the 5-years observation-period 62.7 % (95 % CI 59.0-66.1) of dementia patients still lived in the community in comparison to 86.2 % (95 % CI 85.2-87.2) of controls. Cox regression models show that the risk for institutionalization is 3.45 (95 % CI 3.05-3.90) times higher in dementia patients in comparison to controls when adjusted for sex, age, and comorbidity.
Our analysis shows a significant influence of dementia on institutionalization in comparison to age- and sex-matched controls, especially in the youngest age groups. Hence, the results add substantial information on the disease progression of dementia and are, therefore, of great importance for health-care as well as long-term care planning.
No preview · Article · Jun 2014 · Social Psychiatry and Psychiatric Epidemiology
[Show abstract][Hide abstract] ABSTRACT: Diabetes mellitus is highly prevalent and can lead to serious complications and mortality. Patient education can help to avoid negative outcomes, but up to half of the patients do not participate. The aim of this study was to analyze patients' attitudes towards diabetes education in order to identify barriers to participation and develop strategies for better patient education.
We conducted a qualitative study. Seven GP practices were purposively selected based on socio-demographic data of city districts in Hamburg, Germany. Study participants were selected by their GPs in order to increase participation. Semi-structured face-to-face interviews were conducted with 14 patients. Interviews were audiotaped and transcribed verbatim. The sample size was determined by data saturation. Data were analysed by qualitative content analysis. Categories were determined deductively and inductively.
The interviews yielded four types of barriers: 1) Statements and behaviour of the attending physician influence the patients' decisions about diabetes education. 2) Both, a good state of health related to diabetes and physical/psychosocial comorbidity can be reasons for non-participation. 3) Manifold motivational factors were discussed. They ranged from giving low priority to diabetes to avoidance of implications of diabetes education as being confronted with illness narratives of others. 4) Barriers also include aspects of the patients' knowledge and activity.
First, physicians should encourage patients to participate in diabetes education and argue that they can profit even if actual treatment and examination results are promising. Second, patients with other priorities, psychic comorbidity or functional limitations might profit more from continuous individualized education adapted to their specific situation instead of group education. Third, it might be justified that patients do not participate in diabetes education if they have slightly increased blood sugar values only and no risk for harmful consequences or if they already have sufficient knowledge on diabetes.
[Show abstract][Hide abstract] ABSTRACT: Background: Family practices are the usual setting of clinical primary care. Attempts of involving a department of family practice in the clinical care of an university hospital are rare. At the University Medical Center Hamburg-Eppendorf, Germany, such a pilot project was implemented from October to December of 2012 and evaluated afterwards. Method: The clinical activity of the Department of Primary Medical Care (IfA) of the University Hospital Eppendorf Hamburg (UKE), comprises an ambulatory healthcare center (MVZ) as well as primary medical care in the emergency department (ZNA) at the UKE. The pilot project data (N = 263 from October to December 2012) were analyzed regarding the waiting times and the medical services offered, including the hospital's clinical laboratory, computer-tomography/magnetic resonance imaging and interdisciplinary consultations. This was then compared to a control group derived from a sample of ZNA cases from October of 2011 (N = 1684 cases). The satisfaction with the IfA's involvement in the hospital emergency room was evaluated using a validated patient satisfaction questionnaire (pre-post including 2 unpaired consecutive samples). Results: A total of 263 patients (162 female, 101 male) were treated by the IfA in the emergency department of the UKE. In these cases the median waiting time was 48 minutes and in less than a quarter of these, additional services such as laboratory work (20%), interdisciplinary consultations (18%) or X-rays (2%) were needed. Only 17 cases (6%) needed in-patient treatment. The mean out-patient costs were significantly lower (16,76 Euro; confidence interval (CI) 13,40-19,62 Euro) compared to a control group in the UKE emergency room in October 2011 (52,21 Euro; CI 49,16-55,26 Euro; p < 0,0001). The patient contentedness, while already good, could even be enhanced. Conclusions: The integration of a department of family practice in the every-day practice of an university hospital combining the activity in an emergency department and an ambulatory healthcare center for primary care could be a good future model.
[Show abstract][Hide abstract] ABSTRACT: We compared the prevalence of dementia in nursing home residents and community-dwelling older adults .
Using health insurance claims data for the year 2009, we estimated the prevalence of at least three of four quarters with a diagnosis of dementia in persons aged ≥65 years.
Of 213,694 persons aged 65+ years, 4,584 (2.2 %) lived in nursing homes. The prevalence of dementia was 51.8 % (95 % CI 50.4-53.3) in nursing home residents and 2.7 % (95 % CI 2.6-2.8) in community-dwelling elderly. Increasing prevalences with age were found in both sexes in community-dwelling elderly. These trends were not seen in nursing home residents where prevalences were already high for the age group 65-69 years (35.7 % in males and 40.9 % in females, respectively).
More than half of nursing home residents suffer from dementia, which is about 19-fold higher than the prevalence in insured living in the community.
No preview · Article · Mar 2014 · Aging - Clinical and Experimental Research
[Show abstract][Hide abstract] ABSTRACT: Purpose:
The concept of mild cognitive impairment (MCI) has recently been introduced into the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as mild neurocognitive disorder, making it a formal diagnosis. We investigated the prognostic value of such a diagnosis and analyzed the determinants of the future course of MCI in the AgeCoDe study (German Study on Ageing, Cognition, and Dementia in Primary Care Patients).
We recruited 357 patients with MCI aged 75 years or older from primary care practices and conducted follow-up with interviews for 3 years. Depending on the course of impairment over time, the patients were retrospectively split into 4 groups representing remittent, fluctuating, stable, and progressive courses of MCI. We performed ordinal logistic regression analysis and classification and regression tree (CART) analysis.
Overall, 41.5% of the patients had remission of symptoms with normal cognitive function 1.5 and 3 years later, 21.3% showed a fluctuating course, 14.8% had stable symptoms, and 22.4% had progression to dementia. Patients were at higher risk for advancing from one course to the next along this spectrum if they had symptoms of depression, impairment in more than 1 cognitive domain, or more severe cognitive impairment, or were older. The result on a test of the ability to learn and reproduce new material 10 minutes later was the best indicator at baseline for differentiating between remittent and progressive MCI. Symptoms of depression modified the prognosis.
In primary care, about one-quarter of patients with MCI have progression to dementia within the next 3 years. Assessments of memory function and depressive symptoms are helpful in predicting a progressive vs a remittent course. When transferring the concept of MCI into clinical diagnostic algorithms (eg, DSM-5), however, we should not forget that three-quarters of patients with MCI stayed cognitively stable or even improved within 3 years. They should not be alarmed unnecessarily by receiving such a diagnosis.
Full-text · Article · Mar 2014 · The Annals of Family Medicine
[Show abstract][Hide abstract] ABSTRACT: The evidence of undertreatment of pain in patients with dementia is inconsistent. This may largely be due to methodological differences and shortcomings of studies. In a large cohort of patients with incident dementia and age- and sex-matched controls we examined (1) how often they receive diagnoses indicating pain, (2) how often they receive analgesics and (3) in which agents and formulations.
Using health insurance claims data we identified 1,848 patients with a first diagnosis of dementia aged >= 65 years and 7,385 age- and sex-matched controls. We analysed differences in diagnoses indicating pain and analgesic drugs prescribed between these two groups within the incidence year. We further fitted logistic regression models and stepwise adjusted for several covariates to study the relation between dementia and analgesics.
On average, patients were 78.7 years old (48% female). The proportions receiving at least one diagnosis indicating pain were similar between the dementia and control group (74.4% vs. 72.5%; p = 0.11). The proportion who received analgesics was higher in patients with dementia in the crude analysis (47.5% vs. 44.7%; OR: 1.12; 95% CI: 1.01-1.24), but was significantly lower when adjusted for socio-demographic variables, care dependency, comorbidities and diagnoses indicating pain (OR: 0.78; 95% CI: 0.68-0.88). Analgesics in liquid form such as metamizole and tramadol were more often used in dementia.
Our findings show a comparable documentation of diagnoses indicating pain in persons with incident dementia compared to those without. However, there still seems to be an undertreatment of pain in patients with dementia. Irrespective of dementia, analgesics seem to be more often prescribed to sicker patients and to control pain in the context of mobility.
[Show abstract][Hide abstract] ABSTRACT: Working memory, the capacity of actively maintaining task-relevant information during a cognitive task, is a heritable trait. Working memory deficits are characteristic for many psychiatric disorders. We performed genome-wide gene set enrichment analyses in multiple independent data sets of young and aged cognitively healthy subjects (n = 2,824) and in a large schizophrenia case-control sample (n = 32,143). The voltage-gated cation channel activity gene set, consisting of genes related to neuronal excitability, was robustly linked to performance in working memory-related tasks across ages and to schizophrenia. Functional brain imaging in 707 healthy participants linked this gene set also to working memory-related activity in the parietal cortex and the cerebellum. Gene set analyses may help to dissect the molecular underpinnings of cognitive dimensions, brain activity, and psychopathology.
[Show abstract][Hide abstract] ABSTRACT: We analyzed the differences in morbidity patterns of chronic diseases between long-term care dependent persons in nursing homes compared to those dwelling in the community. We also investigated morbidity differences between long-term care need stages in Germany.
The study included claims data of one nationwide operating statutory health insurance in 2006. Inclusion criteria were age ≥ 65 years, minimum 1 out of 46 diagnoses in at least 3 quarters of the year (n = 8,670). A comparison population was formed with n = 114,962. Prevalences, relative risks, and odds ratios for the risk of nursing home care were calculated.
In the bivariate analysis, only three chronic diseases - dementia, urinary incontinence, and chronic heart failure - showed a higher risk for nursing home care. Regression analysis revealed that only dementia showed higher odds related to the stage of nursing needs.
Among the chronic diseases, only dementia shows a substantially elevated risk for nursing home care. Risk studies on other chronic diseases associated with higher risks of long-term care dependency and specific intervention strategies aiming at delaying or preventing nursing home admission should be developed.
No preview · Article · Feb 2014 · Zeitschrift für Gerontologie + Geriatrie
[Show abstract][Hide abstract] ABSTRACT: Objective:
On the basis of data from one German Sickness Fund we analyzed which medical discipline coded the incident diagnosis of dementia in ambulatory medical care in Germany, which type of dementia was coded and how the initial code eventually changed during the year of incidence.
Claims data of 1,848 insured people aged ≥ 65 years in 2004 with incident dementia were analyzed by means of descriptive statistics.
The diagnosis within the first quarter of the incidence year was coded by the GP in 71%, by a psychiatrist or neurologist in 14%, by both in 6% and by other disciplines in 9% of the cases. The percentage of unspecified diagnoses was 62% among GPs and 46% among psychiatrists or neurologists, a number differing largely from epidemiological studies. In 27% of the cases patients received two or more different dementia diagnoses during the incidence year.
Studies and care concepts regarding dementia on the basis of diagnosis codes in ambulatory claims data should be interpreted with great caution.
No preview · Article · Sep 2013 · Psychiatrische Praxis
[Show abstract][Hide abstract] ABSTRACT: Hintergrund
Ältere Menschen sind oftmals durch mehrere Krankheiten belastet. Mit der daraus resultierenden mehrfachen Medikamenteneinnahme steigt das Risiko für unerwünschte Arzneimittelereignisse. Mit Wirkstofflisten (Beers-Liste, PRISCUS-Liste) soll dieses Risiko für ältere Patienten reduziert werden. Wir stellen hier eine längsschnittliche Analyse (4,5 Jahre) zur Einnahme potenziell inadäquater Medikamente (PIM) in einer Kohorte von hausärztlichen Patienten im Alter von ≥ 75 Jahren vor.
Die Daten wurden für die prospektive, multizentrische Beobachtungsstudie „German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe)“ bei initial 3327 Patienten erhoben. Über eine Medikamentenanamnese bei den Patienten zu Hause ermittelten wir die Häufigkeit der PIM-Einnahme und analysierten die Anteile einzelner PIM-Wirkstoffgruppen über die Zeit.
Gemäß der PRISCUS-Liste betrug der Anteil von Patienten mit PIM-Einnahme zu Studienbeginn 28,7 % und sank 4,5 Jahre später auf 25,0 % (χ2: 7,87; p = 0,004). Gemessen an der Beers-Liste lag der Anteil zu Beginn bei 21,0 % und nahm 4,5 Jahre später auf 17,1 % ab (χ2: 10,77; p = 0,000). Das zeitabhängige Mehrebenenmodell bestätigt dies. Hohes Alter, Depression und die Einnahme vieler rezeptpflichtiger Medikamente sind unabhängige Risikofaktoren für eine PIM-Einnahme gemäß PRISCUS-Liste.
Wir sehen in unseren Ergebnissen einen Trend zur rationaleren Arzneimitteltherapie, weil weniger älteren Patienten PIM verordnet werden. Dies senkt das Risiko für unerwünschte Wirkungen und Nebenwirkungen und die dafür aufzuwendenden Kosten.