[Morbidity differences according to nursing stage and nursing setting in long-term care patients: Results of a claims data based study]

BACKGROUND

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSION

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.

Predictors of Frailty in Old Age - Results of a Longitudinal Study

OBJECTIVES

To investigate time-dependent predictors of frailty in old age longitudinally.

DESIGN

Population-based prospective cohort study.

SETTING

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).

PARTICIPANTS

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.

MEASUREMENTS

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).

RESULTS

Fixed effects regressions revealed that frailty increased significantly with increasing age (β=.2) as well as the occurrence of depression (β=.5) and dementia (β=.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.

CONCLUSION

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.

Mortality in incident dementia - results from the German Study on Aging, Cognition, and Dementia in Primary Care Patients

OBJECTIVE

Dementia is known to increase mortality, but the relative loss of life years and contributing factors are not well established. Thus, we aimed to investigate mortality in incident dementia from disease onset.

METHOD

Data were derived from the prospective longitudinal German AgeCoDe study. We used proportional hazards models to assess the impact of sociodemographic and health characteristics on mortality after dementia onset, Kaplan-Meier method for median survival times.

RESULTS

Of 3214 subjects at risk, 523 (16.3%) developed incident dementia during a 9-year follow-up period. Median survival time after onset was 3.2 years (95% CI = 2.8-3.7) at a mean age of 85.0 (SD = 4.0) years (≥2.6 life years lost compared with the general German population). Survival was shorter in older age, males other dementias than Alzheimer's, and in the absence of subjective memory complaints (SMC).

CONCLUSION

Our findings emphasize that dementia substantially shortens life expectancy. Future studies should further investigate the potential impact of SMC on mortality in dementia.

[Use and potential risks of over-the-counter analgesics]

BACKGROUND AND AIM

We investigated the use of prescription and non-prescription (over-the-counter, OTC) analgesics and the associated risks in elderly patients with multiple morbidities.

METHODS

Pain medication use was evaluated from the baseline data (2008/2009) of the MultiCare cohort enrolling elderly patients with multiple morbidities who were treated by primary care physicians (trial registration: ISRCTN89818205). We considered opioids (N02A), other analgesics, and antipyretics (N02B) as well as nonsteroidal anti-inflammatory drugs (NSAIDs; M01A). OTC use, duplicate prescription, dosages, and interactions were examined for acetylsalicylic acid, diclofenac, (dex)ibuprofen, naproxen, and acetaminophen.

RESULTS

Of 3,189 patients with multiple morbidities aged 65-85 years, 1,170 patients reported to have taken at least one prescription or non-prescription analgesic within the last 3 months (36.7 %). Of these, 289 patients (24.7 % of 1,170) took at least one OTC analgesic. Duplicate prescription was observed in 86 cases; 15 of these cases took the analgesics regularly. In two cases, the maximum daily dose of diclofenac was exceeded due to duplicate prescription. In 235 cases, patients concurrently took a drug with a potentially clinically relevant interaction. In 43 cases (18.3 % of 235) an OTC analgesic, usually ibuprofen, was involved.

DISCUSSION

About one third of the elderly patients took analgesics regularly or as needed. Despite the relatively high use of OTC analgesics, the proportions of duplicate prescription, medication overdoses, and adverse interactions due to OTC products was low.

[Patient Participation in Development of Quality Indicators using the Example of National Disease Management Guidelines for Chronic Heart Failure - A Qualitative Analysis of Collective Perspectives]

PURPOSE

In this qualitative study it was investigated by group discussions with patients suffering from chronic heart failure, how relevant the existing quality indicators of the National Disease Management Guidelines for Chronic Heart Failure are being estimated.

METHODS

6 group discussions were performed. The sample was formed from 4 mixed-gender groups, a male group and a female group. Participants were recruited from local heart sports groups. For the interpretation a method similar to the grounded theory was used.

RESULTS

The main conclusion is that in principle quality indicators are accepted. However, many of these indicators neglect the everyday aspects of patients' life. Participants show a disposition of "yes - but" regarding the quality indicators. This phenomenon could be theoretically grasped using the concept of order of knowledge. While participants keep referring to an order of everyday knowledge, quality indicators make recourse to a medical order of knowledge. Both orders of knowledge may compete with each other.

CONCLUSIONS

The professional knowledge order of medicine needs to open up to a patients' knowledge order. Patient representatives in health care bodies need to be trained to develop a reflexive point of view to different knowledge orders enabling them to represent patients' everyday knowledge more confidently. Otherwise there is danger of conformation to the professional knowledge order of medicine only for reasons of being recognised as equal partners.

[Need for guideline recommendations on treatment of late-life depression from the perspective of experts]

Using a qualitative study approach (expert interview/focus group) the present work explores the question of the necessity of guideline recommendations for the treatment of depression in old age from the experts' perspective. In addition to positive aspects such as signal effect, pooling of knowledge and standardisation of treatment, also many doubts and obstacles are identified and place the practical feasibility of such a treatment recommendation in question. Different factors, such as content- or creative-related aspects (e. g., brevity and clarity) and development-related aspects (e. g. participation of all relevant professional societies) need to be taken into account in the development of guideline recommendations.

[Stability of long-term professional objectives of young physicians during postgraduate training. Results of a multicenter cohort study]

INTRODUCTION

We investigated persistences and changes of career preferences of medical residents in Germany after two years of postgraduate training with regard to future working place and position. The results are compared with those forwarded at graduation from medical school in a gender comparative perspective.

METHODS

The study is based on a standardized postal survey among the participants in the "KarMed" study, originally based on 1012 graduates of the medical faculties of Erlangen, Giessen, Hamburg, Heidelberg, Cologne, Leipzig and Magdeburg in 2009. 2107 persons were contacted. The return rate at baseline was 48 %, and the two surveys after the baseline reached return rates of 87 % and 89 % respectively. In all samples 2/3 were women as in actual medical undergraduate education. Descriptive statistics and regression analysis were performed.

RESULTS

After 2 years of residency, residents after 2 years of postgraduate training still preferred the hospital over private practice as their final workplace after postgraduate training. The attractiveness of leading positions in the hospital declined among men, whereas it was already low for women at graduation. A large proportion of those physicians preferring the ambulatory sector, especially women, wishes to work as employee instead of private practice. At the personal level, almost 60 % forwarded the same preferences as those at graduation. Gender, parenthood and region of study (East vs. West Germany) did not influence stability or change of preferences.

CONCLUSION

The results demonstrate the persistence of professional preferences regarding future sector and position of medical work during postgraduate training. These preferences do neither match with principles of gender equality nor with future workforce needs (e. g. in primary care).

Apolipoprotein E epsilon 4 genotype and a physically active lifestyle in late life: analysis of gene-environment interaction for the risk of dementia and Alzheimer's disease dementia

BACKGROUND

As physical activity may modify the effect of the apolipoprotein E (APOE) ε4 allele on the risk of dementia and Alzheimer's disease (AD) dementia, we tested for such a gene-environment interaction in a sample of general practice patients aged ⩾75 years.

METHOD

Data were derived from follow-up waves I-IV of the longitudinal German study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe). The Kaplan-Meier survival method was used to estimate dementia- and AD-free survival times. Multivariable Cox regression was used to assess individual associations of APOE ε4 and physical activity with risk for dementia and AD, controlling for covariates. We tested for gene-environment interaction by calculating three indices of additive interaction.

RESULTS

Among the randomly selected sample of 6619 patients, 3327 (50.3%) individuals participated in the study at baseline and 2810 (42.5%) at follow-up I. Of the 2492 patients without dementia included at follow-up I, 278 developed dementia (184 AD) over the subsequent follow-up interval of 4.5 years. The presence of the APOE ε4 allele significantly increased and higher physical activity significantly decreased risk for dementia and AD. The co-presence of APOE ε4 with low physical activity was associated with higher risk for dementia and AD and shorter dementia- and AD-free survival time than the presence of APOE ε4 or low physical activity alone. Indices of interaction indicated no significant interaction between low physical activity and the APOE ε4 allele for general dementia risk, but a possible additive interaction for AD risk.

CONCLUSIONS

Physical activity even in late life may be effective in reducing conversion to dementia and AD or in delaying the onset of clinical manifestations. APOE ε4 carriers may particularly benefit from increasing physical activity with regard to their risk for AD.