The assessment of changes in cognitive functioning in the elderly: age- and education-specific reliable change indices for the SIDAM

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.

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.

Effect of cardiovascular and metabolic disease on cognitive test performance and cognitive change in older adults

OBJECTIVES

To examine the effect of cardiovascular and metabolic diseases on initial cognitive test performance and rate of change in three cognitive measures.

DESIGN

Prospective cohort study.

SETTING

General practices in six towns throughout Germany.

PARTICIPANTS

Three thousand three hundred twenty-seven participants aged 75 and older (average 79.7 ± 3.6).

MEASUREMENTS

Data were collected during home visits every 18 months and included sociodemographic variables, depression, disease status, drug intake, and cognition.

RESULTS

Although the presence of transient ischemic attack (TIA) or stroke and diabetes mellitus was related to poor initial cognitive test performance, the presence of those and other far-reaching chronic diseases or a higher disease burden were not related to the rate of change in cognition over time.

CONCLUSION

Diabetes mellitus, stroke and TIA affect cognitive test performance beyond well-known sociodemographic variables and depressive symptoms, although none of these diseases contributed to cognitive decline over time. In practical terms, prevention and diagnosis of cardiovascular and metabolic diseases may be essential to cognitively healthy aging.

Coping with multimorbidity in old age--a qualitative study

Background

Comparatively few studies address the problems related to multimorbidity. This is surprising, since multimorbidity is a particular challenge for both general practitioners and patients. This study focuses on the latter, analyzing the way patients aged 65–85 cope with multimorbidity.

Methods

19 narrative in-depth interviews with multimorbid patients were conducted. The data was analysed using grounded theory. Of the 19 interviewed patients 13 were female and 6 male. Mean age was 75 years. Participating patients showed a relatively homogeneous socio-economic status. Patients were recruited from the German city of Hamburg and the state of North Rhine-Westphalia.

Results

Despite suffering from multimorbidity, interviewees held positive attitudes towards life: At the social level, patients tried to preserve their autonomy to the most possible extent. At the emotional level, interviewees oscillated between anxiety and strength - having, however, a positive approach to life. At the practical level, patients aimed at keeping their diseases under control. The patients tended to be critical in regards to medication.

Conclusions

These findings might have implications for the treatment of multimorbid patients in primary care and further research: The generally presumed passivity of older individuals towards medical treatment, which can be found in literature, is not evident among our sample of older patients. In future, treatment of these patients might take their potential for pro-active cooperation more strongly into account than it is currently the case.

Influence of social support on cognitive change and mortality in old age: results from the prospective multicentre cohort study AgeCoDe

Background

Social support has been suggested to positively influence cognition and mortality in old age. However, this suggestion has been questioned due to inconsistent operationalisations of social support among studies and the small number of longitudinal studies available. This study aims to investigate the influence of perceived social support, understood as the emotional component of social support, on cognition and mortality in old age as part of a prospective longitudinal multicentre study in Germany.

Methods

A national subsample of 2,367 primary care patients was assessed twice over an observation period of 18 months regarding the influence of social support on cognitive function and mortality. Perceived social support was assessed using the 14-item version of the FSozU, which is a standardised and validated questionnaire of social support. Cognition was tested by the neuropsychological test battery of the Structured Interview for the Diagnosis of Dementia (SIDAM). The influence of perceived support on cognitive change was analysed by multivariate ANCOVA; mortality was analysed by multivariate logistic and cox regression.

Results

Sample cognitive change (N = 1,869): Mean age was 82.4 years (SD 3.3) at the beginning of the observation period, 65.9% were female, mean cognition was 49 (SD 4.4) in the SIDAM. Over the observation period cognitive function declined in 47.2% by a mean of 3.4 points. Sample mortality (N = 2,367): Mean age was 82.5 years (SD 3.4), 65.7% were female and 185 patients died during the observation period. Perceived social support showed no longitudinal association with cognitive change (F = 2.235; p = 0.135) and mortality (p = 0.332; CI 0.829-1.743).

Conclusions

Perceived social support did not influence cognition and mortality over an 18 months observation period. However, previous studies using different operationalisations of social support and longer observation periods indicate that such an influence may exist. This influence is rather small and the result of complex interaction mechanisms between different components of social support; the emotional component seems to have no or only a limited effect. Further research is needed to describe the complex interactions between components of social support. Longer observation periods are necessary and standardised operationalisations of social support should be applied.

Natural killer (NK) and NK-like cells at mucosal epithelia: Mediators of anti-microbial defense and maintenance of tissue integrity

Natural killer (NK) cells are innate lymphocytes that play important roles in the defense against microbial pathogens through secretion of IFN-γ and recognition and lysis of virally or bacterially infected host cells. A recently identified population of NK-like cells that shares characteristics of both NK cells and lymphoid tissue inducer (LTi) cells promotes innate immune responses in epithelial tissue through the secretion of IL-22. In contrast to classical NK cells, NK-like cells are localized preferentially at mucosal sites, such as the intestinal mucosa. In this review, we consider the function of NK and NK-like cells in anti-microbial defense as well as the maintenance of tissue integrity in the mucosal epithelium of the intestine, lung, and female reproductive tract. Current experimental evidence supports an important protective role for IL-22-producing NK-like cells during intestinal infections, whereas classical NK cells are crucial in the early defense against many pathogens in the respiratory tract. NK cells isolated from the pregnant uterus differ significantly in phenotype and function from those at other tissue locations. Uterine NK cells clearly contribute to the tissue remodeling that takes place during placentation, but their role in anti-microbial defense remains largely undefined.

Cued recall and other cognitive tasks to facilitate dementia recognition in primary care

OBJECTIVES

To compare the accuracy of commonly used tasks with that of the Visual Association Test (VAT), a conceptually different test involving cued recall of pictorial stimuli, in the recognition of dementia within primary care.

DESIGN

A cross-sectional diagnostic study of concurrent validity.

SETTING

Twenty-nine German primary care practices.

PARTICIPANTS

Four hundred twenty-three individuals in primary care participating in a longitudinal cohort study.

MEASUREMENTS

Participants underwent a comprehensive neuropsychological interview. The validated clinical dementia diagnosis was used as reference standard. Index tests comprised the VAT, Mini-Cog, clock drawing, verbal fluency, episodic memory, and subjective complaints. Validity parameters were calculated; possible confounders of test performance (age, sex, education, comorbidity, depression, language) were evaluated.

RESULTS

Twenty-one participants (5%) had dementia according to the reference standard. The VAT distinguished dementia from nondementia with a sensitivity of 95.2% (95% confidence interval (CI) = 86.1-100.0), a specificity of 96.0% (95% CI = 94.1-97.9), a positive predictive value (PPV) of 55.6% (95% CI = 39.3-71.8), and a negative predictive value (NPV) of 99.7% (95% CI = 99.2-100.0). The next-most-accurate tasks were the Mini-Cog and immediate and delayed recall. Their sensitivity and NPV are similar to those of the VAT, but their PPV and specificity were significantly lower than those of the VAT. Age and depression affected all test scores.

CONCLUSION

The VAT (cued recall of pictorial material) is superior to other tasks for the recognition of dementia in terms of higher specificity and PPV. Age-specific cutoff scores may improve the validity of all tests.

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.

Negligible penetration of incidental amounts of alpha-hydroxy acid from rinse-off personal care products in human skin using an in vitro static diffusion cell model

Alpha-hydroxy acids (AHAs), primarily glycolic and lactic acids, are widely used in cosmetics to alleviate dyspigmentation, photodamage, and other aging skin conditions and as pH adjusters. Glycolic acid reportedly enhances skin damage after repeated ultraviolet light exposure, e.g., increased sunburn cell formation. This study assessed potential in vitro skin penetration of lactic acid and malic acid incorporated into rinse-off personal care products, compared with rinse-off and leave-on exposures to glycolic acid (10%, pH 3.5) in a reference lotion. Radiolabeled AHA-fortified shampoo, conditioner, and lotion were evenly applied as single doses to human epidermal membranes mounted in static diffusion cells (not occluded). Exposures were 1-3 min (rinse-off) or 24 h (leave-on). Epidermal penetration of malic acid and lactic acid from the rinse-off shampoo and conditioner, respectively, was negligible, with >99% removed by rinsing, a negligible portion remaining in the stratum corneum (≤0.15%), and even less penetrating into the viable epidermis (≤0.04%). Glycolic acid penetration from the leave-on reference lotion was 1.42 μg equiv./cm2/h, with total absorbable dose recovery (receptor fluid plus epidermis) of 2.51%, compared to 0.009%, 0.003%, and 0.04% for the rinse-off reference lotion, shampoo (malic acid), and conditioner (lactic acid) exposures, respectively. Dermal penetration of AHAs into human skin is pH-, concentration-, and time-dependent. Alpha-hydroxy acids in rinse-off shampoos and conditioners are almost entirely removed from the skin within minutes by rinsing (resulting in negligible epidermal penetration). This suggests that ultraviolet radiation-induced skin effects of AHA-containing rinse-off products are negligible.

Awareness of local dementia services among general practitioners with academic affiliation

BACKGROUND AND AIMS

Cooperation with specialized services is one important resource for general practitioners (GPs) in managing dementia patients and caregivers.

METHODS

In a questionnaire study among GPs involved in university teaching (n=137) we asked if GPs knew of four types of local dementia services. A linear regression analysis was conducted to find associations with GPs' awareness.

RESULTS

Day care services could be named by over two-thirds of GPs, patient support groups by nearly half, carer support groups and memory clinics by only 40%. Greater awareness of services was associated with better theoretical knowledge of dementia and GP practices in urban areas.

CONCLUSIONS

In the light of the specificity of our GP sample, our results display remarkably poor awareness of institutions caring for demented patients and their relatives. A more active approach in acquainting GPs with dementia services, especially in rural areas, may enhance awareness and cooperation.

Malperformance in verbal fluency and delayed recall as cognitive risk factors for impairment in instrumental activities of daily living

BACKGROUND

Maintaining independence in instrumental activities of daily living (IADL) is crucial for older adults. This study explored the association between cognitive and functional performance in general and in single IADL domains. Also, risk factors for developing IADL impairment were assessed.

METHODS

Here, 3,215 patients aged 75-98 years were included. Data were collected during home visits.

RESULTS

Cognitive functioning was associated with IADL both cross-sectionally and longitudinally. Regarding the single IADL domains cross-sectionally, executive functioning was especially associated with shopping, while episodic memory was associated with responsibility for own medication.

CONCLUSION

Reduced performance in neuropsychological tests is associated with a greater risk of current and subsequent functional impairment.

Prediction of dementia in primary care patients

Background

Current approaches for AD prediction are based on biomarkers, which are however of restricted availability in primary care. AD prediction tools for primary care are therefore needed. We present a prediction score based on information that can be obtained in the primary care setting.

Methodology/Principal Findings

We performed a longitudinal cohort study in 3.055 non-demented individuals above 75 years recruited via primary care chart registries (Study on Aging, Cognition and Dementia, AgeCoDe). After the baseline investigation we performed three follow-up investigations at 18 months intervals with incident dementia as the primary outcome.

The best set of predictors was extracted from the baseline variables in one randomly selected half of the sample. This set included age, subjective memory impairment, performance on delayed verbal recall and verbal fluency, on the Mini-Mental-State-Examination, and on an instrumental activities of daily living scale. These variables were aggregated to a prediction score, which achieved a prediction accuracy of 0.84 for AD. The score was applied to the second half of the sample (test cohort). Here, the prediction accuracy was 0.79. With a cut-off of at least 80% sensitivity in the first cohort, 79.6% sensitivity, 66.4% specificity, 14.7% positive predictive value (PPV) and 97.8% negative predictive value of (NPV) for AD were achieved in the test cohort. At a cut-off for a high risk population (5% of individuals with the highest risk score in the first cohort) the PPV for AD was 39.1% (52% for any dementia) in the test cohort.

Conclusions

The prediction score has useful prediction accuracy. It can define individuals (1) sensitively for low cost-low risk interventions, or (2) more specific and with increased PPV for measures of prevention with greater costs or risks. As it is independent of technical aids, it may be used within large scale prevention programs.

Do general practitioners recognize mild cognitive impairment in their patients?

OBJECTIVES

The need for recognition of mild cognitive impairment (MCI) in primary care is increasingly discussed because MCI is a risk factor for dementia. General Practitioners (GPs) could play an important role in the detection of MCI since they have regular and long-term contact with the majority of the elderly population. Thus the objective of this study is to find out how well GPs recognize persons with MCI in their practice population.

DESIGN

Cross-sectional study.

SETTING

Primary care chart registry sample.

PARTICIPANTS

3,242 non-demented GP patients aged 75-89 years.

MEASUREMENTS

GPs assessed the cognitive status of their patients on the Global Deterioration Scale (GDS). Thereafter, trained interviewers collected psychometric data by interviewing the patients at home. The interview data constitute the basis for the definition of MCI cases (gold standard).

RESULTS

The sensitivity of GPs to detect MCI was very low (11-12%) whereas their specificity amounts to 93-94%. Patients with MCI with a middle or high level of education more often got a false negative assignment than patients with a low educational level. The risk of a false positive assignment rose with the patients' degree of comorbidity. GPs were better at detecting MCI when memory or two and more MCI-domains were impaired.

CONCLUSION

The results show that GPs recognise MCI in a very limited number of cases when based on clinical impression only. A further development of the MCI concept and its operationalisation is necessary. Emphasis should be placed on validated, reliable and standardised tests for routine use in primary care encompassing other than only cognitive domains and on case finding approaches rather than on screening. Then a better attention and qualification of GPs with regard to the recognition of MCI might be achievable.

Fluoroquinolones to treat uncomplicated acute cough in primary care: predictors for unjustified prescribing of antibiotics

BACKGROUND

Despite efforts to ensure more accurate prescribing of antibiotics for respiratory tract infections, inappropriate selection of antibiotic treatment remains a big issue. We tried to ascertain which factors best predict the nature of fluoroquinolone prescribing for acute cough in primary care.

METHODS

Random effects logistic regression models were applied to the baseline prescription data taken from a cluster-randomized controlled trial based on 104 general practitioners (GPs) and 2745 patients.

RESULTS

Significant predictors for the prescription of fluoroquinolones from both patient and GP data were identified. Predictors from a patient's perspective were the severity of illness {odds ratio (OR) 3.56 [95% confidence interval (CI) 2.45-5.19] P < 0.001}, the duration of illness before seeing the GP [OR 1.09 (95% CI 1.04-1.14) P < 0.020] and the individual patient's age [OR 1.01 (95% CI 1.00-1.01) P < 0.015]. Predictors from the GP's perspective were extent/lack of specific vocational training [OR 3.10 (95% CI 1.54-6.22) P < 0.001], status as a general internist [OR 2.00 (95% CI 1.10-3.70) P < 0.002], the physician's overall antibiotic prescription rate for acute cough [OR 1.02 (95% CI 1.01-1.04) P < 0.001], the duration of illness before contact with patient [OR 0.81 (95% CI 0.69-0.95) P < 0.010] and the severity of illness [OR 0.27 (95% CI 0.12-0.63) P < 0.002].

DISCUSSION

Whether a fluoroquinolone is prescribed by a GP seems to be determined not only by the patient's characteristics but also by the GP's vocational training and overall antibiotic prescribing rate. As the prescription of fluoroquinolones for the treatment of acute coughing can rarely be justified, such prescriptions may serve as a quality indicator for antibiotic prescribing in primary care.

Is the clock drawing test appropriate for screening for mild cognitive impairment?--Results of the German study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe)

BACKGROUND

Individuals with mild cognitive impairment (MCI) are at high risk of developing dementia and are a target group for preventive interventions. Therefore, research aims at diagnosing MCI at an early stage with short, simple and easily administrable screening tests. Due to the fact that the Clock Drawing Test (CDT) is widely used to screen for dementia, it is questionable whether it is suited to screen for MCI.

METHODS

3,198 primary care patients aged 75+ were divided into two groups according to their cognitive status, assessed by comprehensive neuropsychological testing: individuals without MCI and individuals with MCI. The CDT scores, evaluated by the scoring system of Sunderland et al. [J Am Geriatr Soc 1989;37:725-729], of both groups were compared. Multivariate analyses were calculated and the sensitivity and specificity of the CDT to screen for MCI were reported.

RESULTS

Significant differences were found for CDT results: MCI patients obtained worse results than cognitively unimpaired subjects. CDT has a significant impact on the diagnosis of MCI. However, sensitivity and specificity as well as receiver operating characteristic analyses are not adequate, meaning that the CDT could not be named as an exact screening tool.

LIMITATIONS

Applying different CDT versions of administration and scoring could yield different results.

CONCLUSIONS

CDT does not achieve the quality to screen individuals for MCI.

A topologically faithful, tissue-guided, spatially varying meshing strategy for computing patient-specific head models for endoscopic pituitary surgery simulation

This paper presents a method for tessellating tissue boundaries and their interiors, given as input a map consisting of relevant tissue classes of the head, in order to produce anatomical models for finite-element-based simulation of endoscopic pituitary surgery. Our surface meshing method is based on the simplex model, which is initialized by duality from the topologically accurate results of the Marching Cubes algorithm, and which affords explicit control over mesh scale, while using tissue information to adhere to relevant boundaries. Our mesh scale strategy is spatially varying, based on the distance to a central point or linearized surgical path. The tetrahedralization stage also features a spatially varying mesh scale, consistent with that of the surface mesh.

At-risk alcohol drinking in primary care patients aged 75 years and older

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 = 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.

The German MultiCare-study: Patterns of multimorbidity in primary health care - protocol of a prospective cohort study

Background

Multimorbidity is a highly frequent condition in older people, but well designed longitudinal studies on the impact of multimorbidity on patients and the health care system have been remarkably scarce in numbers until today. Little is known about the long term impact of multimorbidity on the patients' life expectancy, functional status and quality of life as well as health care utilization over time. As a consequence, there is little help for GPs in adjusting care for these patients, even though studies suggest that adhering to present clinical practice guidelines in the care of patients with multimorbidity may have adverse effects.

Methods/Design

The study is designed as a multicentre prospective, observational cohort study of 3.050 patients aged 65 to 85 at baseline with at least three different diagnoses out of a list of 29 illnesses and syndromes. The patients will be recruited in approx. 120 to 150 GP surgeries in 8 study centres distributed across Germany. Information about the patients' morbidity will be collected mainly in GP interviews and from chart reviews. Functional status, resources/risk factors, health care utilization and additional morbidity data will be assessed in patient interviews, in which a multitude of well established standardized questionnaires and tests will be performed.

Discussion

The main aim of the cohort study is to monitor the course of the illness process and to analyse for which reasons medical conditions are stable, deteriorating or only temporarily present. First, clusters of combinations of diseases/disorders (multimorbidity patterns) with a comparable impact (e.g. on quality of life and/or functional status) will be identified. Then the development of these clusters over time will be analysed, especially with regard to prognostic variables and the somatic, psychological and social consequences as well as the utilization of health care resources. The results will allow the development of an instrument for prediction of the deterioration of the illness process and point at possibilities of prevention. The practical consequences of the study results for primary care will be analysed in expert focus groups in order to develop strategies for the inclusion of the aspects of multimorbidity in primary care guidelines.

Gene polymorphisms in prodynorphin (PDYN) are associated with episodic memory in the elderly

Cognitive functions show large variation in elderly people and are substantially heritable. Animal studies revealed that dynorphins influence cognition and memory, especially in aged animals. Thus, we tested the effect of four SNPs (rs7272891, rs1997794, rs2235751 and rs910080) and the VNTR promoter polymorphism in the prodynorphin gene (PDYN) on episodic memory and verbal fluency in a large (n = 1619) sample of elderly people (mean age: 80 +/- 3.39 years; range 75-90 years) recruited through the German study on ageing, cognition and dementia in primary care patients (AgeCoDe). We found that carriers of the minor alleles of rs1997794 (P < 0.002) and rs910080 (P < 0.005) presented with higher episodic memory scores than homozygote carriers of the major allele. Also, a three marker haplotype including these two SNPs and rs2235751 was associated with better episodic memory scores. Verbal fluency scores were non-significantly better in carriers of these respective alleles. Thus, our results suggest a role of PDYN gene variations in determining memory function also in elderly humans.

Reducing unnecessary prescriptions of antibiotics for acute cough: adaptation of a leaflet aimed at Turkish immigrants in Germany

Background

The reduction in the number of unnecessary prescriptions of antibiotics has become one of the most important objectives for primary health care. German GPs report that they are under "pressure to prescribe" antibiotics particularly in consultations with Turkish immigrants. And so a qualitative approach was used to learn more about the socio-medical context of Turkish patients in regard to acute coughs. A German leaflet designed to improve the doctor-patient communication has been positively tested and then adapted for Turkish patients.

Methods

The original leaflet was first translated into Turkish. Then 57 patients belonging to 8 different GPs were interviewed about the leaflet using a semi-standardised script. The material was audio recorded, fully transcribed, and analysed by three independent researchers. As a first step a comprehensive content analysis was performed. Secondly, elements crucial to any Turkish version of the leaflet were identified.

Results

The interviews showed that the leaflets' messages were clearly understood by all patients irrespective of age, gender, and educational background. We identified no major problems in the perception of the translated leaflet but identified several minor points which could be improved. We found that patients were starting to reconsider their attitudes after reading the leaflet.

Conclusion

The leaflet successfully imparted relevant and new information to the target patients. A qualitative approach is a feasible way to prove general acceptance and provides additional information for its adaptation to medico-cultural factors.

Östrogen- und Progesteronrezeptoren in malignen Ovarialtumoren

Estrogen receptors (ER) and progesterone receptors (PR) were evaluated in 173 primary ovarian cancers and in 6 ovarian metastases. In epithelial ovarian carcinomas 63% had ER and 46% PR. Almost all granulosa cell tumours were receptor-positive, while sarcomas, dysgerminomas, and teratomas lacked ER and PR. Both receptors were found less often in tumours of the histological grade I than in those of grade II and III. During the development of metastases and during chemotherapy there was a loss of PR in 27% and 53% of the cases, respectively, while the amount of ER remained more or less constant. In addition to ovarian cancers ER and PR were present in carcinomas of the fallopian tube as well. ER-negative and especially PR-negative tumours seemed to respond better to chemotherapy than receptor-positive carcinomas. The possible significance of ER and PR with regard to the success of an endocrine treatment is discussed.

[Discrimination of Blacks on account of their skin colour? Results of focus group discussions with victims in the German health-care system]

BACKGROUND

In spite of a number of researches on immigrants in the German Health System, there has hardly been any research on immigrant's experiences with General Practitioners or research on Black patients. As an example the experiences of Black People (1) with an immigration background from the Democratic Republic of Congo (RDC) with German White GPs was investigated.

METHODS

Two focus groups with a total of 33 participants from the DRC were held and the discussions documented and transcribed. The authors performed a content analysis and developed inductively the categorical system on the basis of the transcription.

RESULTS

The participants underlined their self-competences in health and diseases. Language was mentioned as a problem in communication, but had no priority except for the lack of documents in French. However, they underlined the hectic and unfriendliness of German medical staff as well as lack of respect towards them. They also criticised the insufficient medical competence of German medical doctors concerning diseases, which are common in Africa and the increasing social injustice, bureaucracy and economic efficiency. Experiences with discrimination and racism were clearly expressed and illustrated in its intermingled structure with other forms of discrimination.

CONCLUSIONS

The concept concerning health and diseases of the African immigrants was a Western medical concept, other concepts like, e.g., "African" formed medical concepts did not occur. The many-sided experienced discriminations of Black immigrants in White Surgeries and in the German Health System presumably also correspond to experiences in other areas of German society. A number of critical remarks of the participants corresponded with what we expect from White patients, especially when speaking about communicative abilities of doctors. Better communicative abilities and a better knowledge of the so-called "tropical diseases" are required. But to the same degree it is mandatory to develop the ability of reflecting on discrimination at all levels including racism and "intercultural" opening of the German Health System.

[Needs and wishes of healthy patients - how should physicians deal with them?]

BACKGROUND

It is hardly known how physicians feel and act if patients complain about social damage, familial tragedies or problems at work instead of illnesses or diseases.

METHODS

Seven general practitioners discussed this subject in a focus-group setting. Within two hours, the three female and four male practitioners described some typical needs and wishes of their healthy patients. They were also encouraged to relate their feelings, reactions and behaviour as doctors. We interpreted the transcript of the recorded discussion according to the rules of a content-analysis.

RESULTS

Certificates, (non-medical) advice and information, general care and reducing expenses are the main reasons for healthy patients to see them, the doctors quoted. The doctor's feelings depend on the personality of the patient and the reported problems. As a result, the physician's acceptance of needs and wishes of healthy patients varies over a broad spectrum and the decisions differ and seem arbitrary, although reporting on similar situations. Her/his personal attributes and mood mainly determine their decision about the patient's wishes.

DISCUSSION

The question of whether to refuse or to respect healthy patients' wishes was arbitrary in this focus-group setting. Because no specific medical curriculum exists, rules for doctors' reactions and decisions on social, familial or working problems of their patients could be helpful. In particular, specific problems should be dealt with by social workers and related professions.

Patterns of subjective memory impairment in the elderly: association with memory performance

BACKGROUND

The association of subjective memory impairment (SMI) with cognitive performance in healthy elderly subjects is poor because of confounds such as depression. However, SMI is also a predictor for future dementia. Thus, there is a need to identify subtypes of SMI that are particularly related to inferior memory performance and may represent at-risk stages for cognitive decline.

METHOD

A total of 2389 unimpaired subjects were recruited from the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe), as part of the German Competence Network on Dementia. Clusters of SMI according to patterns of response to SMI questions were identified. Gender, age, depressive symptoms, apolipoprotein E (apoE) genotype, delayed recall and verbal fluency were included in a Classification and Regression Tree (CART) analysis to identify discriminators between the clusters.

RESULTS

We identified three clusters. Cluster 1 contained subjects without memory complaints. Cluster 2 contained subjects with general memory complaints, but mainly without memory complaints on individual tasks of daily living. Cluster 3 contained subjects with general memory complaints and complaints on individual tasks of daily living. Depressive symptoms, as the first-level discriminator, distinguished between clusters 1 and 2 versus cluster 3. In subjects with only a few depressive symptoms, delayed recall discriminated between cluster 1 versus clusters 2 and 3.

CONCLUSIONS

In SMI subjects with only a minor number of depressive symptoms, memory complaints are associated with delayed recall. As delayed recall is a sensitive predictor for future cognitive decline, SMI may be the first manifestation of future dementia in elderly subjects without depression.