[Potentially inappropriate medication in elderly primary care patients : A retrospective, longitudinal analysis]

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.

A hierarchy of predictors for dementia-free survival in old-age: results of the AgeCoDe study

OBJECTIVE

Progression from cognitive impairment (CI) to dementia is predicted by several factors, but their relative importance and interaction are unclear.

METHOD

We investigated numerous such factors in the AgeCoDe study, a longitudinal study of general practice patients aged 75+. We used recursive partitioning analysis (RPA) to identify hierarchical patterns of baseline covariates that predicted dementia-free survival.

RESULTS

Among 784 non-demented patients with CI, 157 (20.0%) developed dementia over a follow-up interval of 4.5 years. RPA showed that more severe cognitive compromise, revealed by a Mini-Mental State Examination (MMSE) score < 27.47, was the strongest predictor of imminent dementia. Dementia-free survival time was shortest (mean 2.4 years) in such low-scoring patients who also had impaired instrumental activities of daily living (iADL) and subjective memory impairment with related worry (SMI-w). Patients with identical characteristics but without SMI-w had an estimated mean dementia-free survival time of 3.8 years, which was still shorter than in patients who had subthreshold MMSE scores but intact iADL (4.2-5.2 years).

CONCLUSION

Hierarchical patterns of readily available covariates can predict dementia-free survival in older general practice patients with CI. Although less widely appreciated than other variables, iADL impairment appears to be an especially noteworthy predictor of progression to dementia.

[The professional and private situation of male and female physicians entering postgraduate medical education in Germany]

AIM

This study investigated the professional and the private situation of medical interns at the onset of their postgraduate training in Germany. We analysed the contractual situation and the working hours in the hospital, the professional situation of the partner and the number of hours invested in private life with special reference to gender and children.

METHOD

A standardised postal survey was conducted among all last year medical students in the medical faculties of Erlangen, Giessen, Hamburg, Heidelberg, Cologne, Leipzig and Magdeburg after entering postgraduate training. 1 009 were contacted for a first follow-up one year later and 87% responded. Descriptive statistics and regression analysis were performed.

RESULTS

The analysis shows that female physicians are disadvantaged compared to males with regard to various professional and private conditions relevant for career development, especially when children are present. We found a large number of hints pointing towards a persistence of traditional role patterns within the couple relationship. These conditions differed substantially between the regions of former German Federal and former German Democratic Republic.

CONCLUSIONS

A growing number of children in the study population in the course of the longitudinal analysis will show if these gender-related differences persist in the course of the training period and which influences on career development can be observed.

Age of major depression onset, depressive symptoms, and risk for subsequent dementia: results of the German study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe)

BACKGROUND

Whether late-onset depression is a risk factor for or a prodrome of dementia remains unclear. We investigated the impact of depressive symptoms and early- v. late-onset depression on subsequent dementia in a cohort of elderly general-practitioner patients (n = 2663, mean age = 81.2 years).

METHOD

Risk for subsequent dementia was estimated over three follow-ups (each 18 months apart) depending on history of depression, particularly age of depression onset, and current depressive symptoms using proportional hazard models. We also examined the additive prediction of incident dementia by depression beyond cognitive impairment.

RESULTS

An increase of dementia risk for higher age cut-offs of late-onset depression was found. In analyses controlling for age, sex, education, and apolipoprotein E4 genotype, we found that very late-onset depression (aged ≥ 70 years) and current depressive symptoms separately predicted all-cause dementia. Combined very late-onset depression with current depressive symptoms was specifically predictive for later Alzheimer's disease (AD; adjusted hazard ratio 5.48, 95% confidence interval 2.41-12.46, p < 0.001). This association was still significant after controlling for cognitive measures, but further analyses suggested that it was mediated by subjective memory impairment with worries.

CONCLUSIONS

Depression might be a prodrome of AD but not of dementia of other aetiology as very late-onset depression in combination with current depressive symptoms, possibly emerging as a consequence of subjectively perceived worrisome cognitive deterioration, was most predictive. As depression parameters and subjective memory impairment predicted AD independently of objective cognition, clinicians should take this into account.

[Recommendations for overcoming interface problems in medical rehabilitation of federal pension funds and statutory health insurance]

OBJECTIVE

Interface problems in medical rehabilitation are a consequence of problems with communication and cooperation, lack of information and transparency. Different stakeholders are trying to solve these problems since many years or decades respectively. Following a series of deficit-oriented studies we tried to develop recommendations for possible solutions of important interface problems together with affected people based on a qualitative analysis of main problem areas.

METHOD

10 separate group discussions with rehabilitation patients, general practitioners and specialists in private practices, representatives of the federal pension fund and statutory health insurance as well as clinicians from rehabilitation clinics and 3 mixed group discussions (all before mentioned groups excluding rehabilitation patients) were conducted. These group discussions served to prepare a semidiurnal final conference. All meetings were recorded and content analyzed or summarized in protocols respectively.

RESULTS

Results are recommendations on strategies to reduce interface problems in medical rehabilitation. Those are: development of a rehabilitation-information-website for insurees and general practitioners and specialists in private practices; changes in forms, applications, notifications; advanced training for general practitioners and specialists in private practices und support in detecting rehabilitation need.

CONCLUSION

Due to divided structures of care provision and increasing specialization, overcoming interface problems is one of the main challenges in the provision of medical rehabilitation. It can be met if different stakeholder approach each other without prejudices, share instead of demarcate competencies and are willing to strike new paths. Our recommendations represent the first step to reaching this goal.

[Blood transfusions: risks beyond communicable diseases]

Blood transfusions are daily practice in orthopaedic surgery and traumatology. Due to new surgical techniques and a better understanding of anaemia-associated pathophysiology, the indications for transfusion are becoming more and more strict. This is even more important as in the past few years increasing evidence shows that blood transfusions have a significant impact on hospital mortality and the patient's outcome. This article is intended to provide an overview of the literature in recent years dealing with this problem.

[Traumatic abruption of the placenta with disseminated intravascular coagulation]

Trauma in pregnancy is infrequent and a systematic primary strategy constitutes a real challenge for the interdisciplinary team. With a high fetal mortality rate and a substantial maternal mortality rate traumatic placental abruption is a severe emergency which every anesthetist should be aware of. After hemodynamic stabilization of the mother and control of the viability of the fetus the therapy of traumatic placental abruption consists mostly of an immediate caesarean section. Coagulopathy by depletion of coagulation factors as well as disseminated intravascular coagulation (DIC) have to be expected and consequently a massive blood loss must be anticipated. Thrombelastography provides assistance for fast differential diagnosis and goal-directed treatment of the disturbed sections of the coagulation cascade.

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.

[The joint research project "Comorbidity and multimorbidity in primary care" (MultiCare)]

MultiCare is the acronym for a multidisciplinary and multicenter research network on multimorbidity and comorbidity in the primary care/family medicine setting, which is coordinated by the Institute of Primary Medical Care of the University Medical Center Hamburg-Eppendorf. Multimorbidity is one of the most difficult problems in primary medical care as little is known about the interaction of several diseases in a person with regard to etiology and disease progress. Also, guidelines for the treatment of multimorbid patients are largely lacking. Therefore, the aims of the MultiCare network include: the identification of multimorbidity patterns in the elderly primary care population, analysis of incidence and prevalence and of interactions within clusters, the investigation of severity and consequences for patients, as well as trials to improve physician-patient interaction in the case of multimorbidity. During the first funding period (2008-2010) the network consisted of two observational and two interventional studies. Their results as of summer 2011 are presented in the following article.

[General practitioner or specialist at home or abroad?]

This study investigated the career preferences of medical graduates in Germany with regard to discipline, place and position after the completion of postgraduate training. We also investigated differences in career options according to gender and region of study (former German Federal Republic vs. former German Democratic Republic).The study is based on a standardised postal survey among all last year medical students in the medical faculties of Erlangen, Giessen, Hamburg, Heidelberg, Cologne, Leipzig and Magdeburg in 2009. 2 107 persons were contacted and 1 012 (48%) participated in the survey.96% of participants stated their intention to pursue a postgraduate training in a medical discipline, and only 0.4% denied such an objective. 7% of the graduates preferred a career towards general practice, and a similar percentage preferred general internal medicine which usually also leads to a primary care activity. 84% aimed at becoming a medical specialist. In total, 28% intended to work in a specialist practice, and 10% in a general practice. Only one-fifth of the latter aimed at working in a countryside setting. 7% aimed at starting postgraduate training outside of Germany, and 8% preferred to work outside Germany after completion of the postgraduate training. In both cases, Switzerland was by far the most preferred country.The results contradict the thesis that young graduates are reluctant to enter clinical medicine. Working abroad is within the scope of less than 10% of the graduates. A dramatic difference between the demand for general practitioners and the career intentions of medical graduates is observed. Measures to increase the attractiveness of primary care, especially in the countryside, are urgently needed.