[Operative risk of geriatric patients in cardiac surgery]

BACKGROUND

Despite substantial progress in interventional cardiology, there are still many geriatric patients who require cardiac surgery. Estimation of the operative risk is therefore of great importance.

OBJECTIVE

The prognostic value of the geriatric assessment for estimation of the operative risk was evaluated.

MATERIAL AND METHODS

Between 2008 and 2009 a geriatric assessment was carried out on 500 patients before an urgent or elective cardiac surgery intervention. The primary endpoints were in-hospital death, death within 30 days after the intervention and stroke. A secondary endpoint was the combination of death, stroke and in-hospital complications.

RESULTS

The average age of the patients was 77.1 ± 4.6 years and 44.3% of the particpants were women. Aortic stenosis was the primary reason for surgery in 49.2% of patients and coronary artery disease in 38.8% of patients. Half of the patients (56.5%) showed functional impairments in one or more evaluated domains. Significant limitations in cognitive function were present in 11.8% and in mobility in 2.4% of the patients. The 30-day mortality was 2.9% and stroke occurred in 1.4% of the patients. After multivariate analysis cognitive impairment remained independently associated with the operative mortality (odds ratio OR 3.8, 95% confidence interval CI 1.2-12.7).

CONCLUSION

The perioperative mortality of older patients in cardiac surgery is low. A limited functional status detected in the geriatric assessment is associated with an increased mortality. Impaired cognitive function is an independent predictor of postoperative mortality.

Health Promotion and Preventive Care Intervention for Older Community-Dwelling People: Long-Term Effects of a Randomised Controlled Trial (RCT) within the LUCAS Cohort

OBJECTIVES

An RCT of a health promotion and preventive care intervention was done in 2001-2002. Here, long-term analyses based on 12 years of follow-up of survival and of change in functional competence between intervention and control group are presented. Positive 1-year results (significantly higher use of preventive services and better health behaviour) were presented earlier.

DESIGN

Parallel group randomised controlled trial (RCT) with 878 participants in the intervention and 1,702 participants in the control group.

SETTING

The study took place in Hamburg, Germany and made use of health care structures and professionals of a geriatrics centre.

PARTICIPANTS

Study participants were initially community-dwelling, aged 60 years and older and without B-ADL-restrictions, cognitive impairment, or need of nursing care, with sufficient command of the German language.

INTERVENTIONS

Health promotion and preventive care interventions relied on an extensive health questionnaire and the subsequent offer to participate in multi-topic personal reinforcement performed in small group sessions or at preventive home visits.

MEASUREMENTS

Primary outcome: Survival time; in some analyses, adjustments were made for gender, age and self-perceived health. Secondary outcome: Functional competence (LUCAS Functional Ability Index) based on responses to self-administered questionnaires at 1-year follow-up and 12 years after 1-year follow-up (2013/2014).

RESULTS

Mean time under observation was 10.3 years. 38.3% (987/2,580) of the participants died; intervention group (IG): 35.7% (313/878), control group (CG): 39.6% (674/1,702); HR=0.89; p=0.09. Functional competence at 1-year follow-up: IG: ROBUST 67.4% (391/580), FRAIL 11.9% (69/580) vs. CG: ROBUST 62.9% (861/1,368), FRAIL 14.8% (203/1,368); p=0.12. 12-years after 1-year follow-up: IG: ROBUST 50.0% (160/320), FRAIL 30.9% (99/320) vs. CG: ROBUST 48.9% (307/628), FRAIL 34.1% (214/628); p=0.56.

CONCLUSIONS

Insignificant but consistent effects on survival and the dynamics of functional competence suggest effectivity of the complex intervention. We plan to take a closer look at the effect of each reinforcement separately.

Pro-Active Fall-Risk Management is Mandatory to Sustain in Hospital-Fall Prevention in Older Patients--Validation of the LUCAS Fall-Risk Screening in 2,337 Patients

OBJECTIVES

Prevention of in-hospital falls contributes to improvement of patient safety. However, the identification of high-risk patients remains a challenge despite knowledge of fall-risk factors. Hence, objective was to prospectively validate the performance of the LUCAS (Longitudinal Urban Cohort Ageing Study) fall-risk screening, based on routine data (fall history, mobility, mental status) and applied by nurses.

DESIGN

Observational study comparing two groups of patients who underwent different fall-risk screenings; the LUCAS screening (2010 - 2011) and the STRATIFY (St. Thomas's Risk Assessment Tool In Falling Elderly Inpatients) (2004 - 2006).

SETTING

Urban teaching hospital.

PARTICIPANTS

Consecutively hospitalized patients (≥ 65 years old) were screened on admission; LUCAS n = 2,337, STRATIFY n = 4,735.

MEASUREMENTS

The proportions of fallers were compared between the STRATIFY and the LUCAS time periods. The number of fallers expected was compared to that observed in the LUCAS time period. Standardized fall-incidence recording included case-note checks for unreported falls. Plausibility checks of fall-risk factors and logistic regression analysis for variable fall-risk factors were performed.

RESULTS

The proportions of fallers during the two time periods were LUCAS n = 291/2,337 (12.5%) vs. STRATIFY n = 508/4,735 (10.7%). After adjustment for risk-factor prevalence, the proportion of fallers expected was 14.5% (334/2,337), the proportion observed was 12.5% (291/2,337) (p = 0.038).

CONCLUSIONS

In-hospital fall prevention including systematic use of the LUCAS fall-risk screening reduced the proportion of fallers compared to that expected from the patients' fall-risk profile. Raw proportions of fallers are not suitable to evaluate fall prevention in hospital because of variable prevalence of patients' fall-risk factors over time. Continuous communication, education and training is needed to sustain in-hospital falls prevention.

[Ideal types of interaction patterns of psychosomatic patients in geriatric inpatient treatment]

BACKGROUND

Cooperation between psychosomatic and geriatric medicine is still sporadic and rarely institutionally integrated. At the same time, however, nearly half of geriatric inpatients suffer from psychopathological symptoms of clinical relevance. The patterns of interactions between patients and professionals of the geriatric team prior to a psychosomatic intervention that lead to a specific consultation are still rarely known. The aim of this paper was to identify these relational patterns, which can again occur during interaction with the psychosomatic patient.

MATERIAL AND METHODS

Protocols from the consultation sessions of 76 geriatric in-patients, treated over a period of 1 year, were used as the basis data for the development of interactional patterns with the systematic, qualitative method of forming ideal types by understanding.

RESULTS

Three groups with a total of 11 interactional patterns were formed: (1) "conflictuous interaction" with patients who re-enact their inner conflicts (e.g., autonomy or conflicts on power and subjugation), (2) "the problem can not be dealt with" with patients who forget or deny and repress their mental problems in other ways, and (3) "avoiding contact" with patients who have different forms of psychosocial withdrawal.

CONCLUSION

Extension of the geriatric functional diagnostic approach on interactional-psychodynamic aspects is possible and fosters a differentiated view on the psychosomatic situation of geriatric patients.

[Resources and risks in old age: the LUCAS-I marker set for a classification of elderly people as fit, pre-frail and frail. First results on validity from the Longitudinal Urban Cohort Ageing Study (LUCAS), Hamburg]

BACKGROUND

There is a need for a simple self-administered instrument to assess frailty in community-dwelling seniors.

METHODS

We present a new marker set to assess the functional state of seniors. Contrary to current literature, we focus not only on risks, but also include resources. The questions relate to facts (ways to do things), rather than on subjective information (e.g. exhaustion). It was developed in the context of the Longitudinal Urban Cohort Ageing Study (LUCAS) in Hamburg, Germany.

RESULTS

The classification based on these questions proposes operational definitions of the terms fit, pre-frail and frail and is predictive for need for nursing care as well as mortality. A wealth of results establishes the validity of the categorisation compared to other health questions. One of the classification questions concerns cycling. For areas where cycling is not suitable, we propose to replace this question with one about independently walking 500 m. However, the cycling question appears to indicate frailty earlier.

CONCLUSION

The self-administered questionnaire provides a simple, cost-effective way to screen seniors for early signs of declining function in order to start preventive action.

[Rehabilitation instead of nursing care. Current state and future demand of geriatric rehabilitation]

In Germany, the term "rehabilitation instead of nursing care" represents an established legal claim and is also an imperative part within the general concept of comprehensive healthcare provision, reflecting the ongoing demographic and epidemiological developments. This report gives an overview on the rationale, the principles, and organizational conception of geriatric rehabilitation. This is completed by an assessment of existing structures for service provision and future demands of specific geriatric rehabilitation and geriatric care. There are well-established possibilities and facilities to realize the legal claim "rehabilitation instead of nursing care." However, these possibilities have to be further optimized in order to detect need earlier and to make adequate use of the potential resources in the growing number of old-aged persons.

[Special care units for the treatment of acutely ill, cognitively impaired geriatric patients in Germany]

During recent years, specialized wards have been established in geriatric hospital departments as a consequence of the growing need of special care for acutely ill older patients, who are also cognitively impaired. However, there are neither established standards nor any commonly agreed concept of care. A written survey among 12 specialized wards in Germany revealed some characteristics of these wards: extended geriatric assessment, special education of staff including validation and gerontopsychiatric issues, and particular equipment/architecture, such as hidden doors and group rooms, and in some cases loop tracks for walking, therapeutic facilities, and 'living rooms' on the wards. There is a wide variability with respect to the designation of these wards, the number of beds, length of stay, and admission criteria. It appears from this survey that there should be an exchange of empirical experience made on these wards, and there is a need of collaborative research on its usefulness.

[Underweight in elderly persons. A retrospective analysis of 3821 forensic autopsies in Hamburg]

AIM AND METHOD

Based on the systematic analyses of a 10-year period at the Institute of Forensic Medicine at the University Clinic Hamburg-Eppendorf, the frequency of underweight in elderly persons at their time of death was retrospectively calculated. Body mass index (BMI) values <20 kg/m(2) were taken as indicative of underweight and the data of 1,551 women and 2,270 men, mean age 69 years (51-101 years) were analyzed.

RESULTS

The prevalence of underweight was 15.4%. Low BMI values were more frequent in women than men (18.8 vs. 13.1%) and more frequent in persons needing professional nursing care at the time of death (28.9%). Underweight increased for the age range 70-79 from about 15% to over 38% for those 90 years and older at the time of death. Pressure sores were documented in 1.8% of cases. Persons in need of professional nursing care more often had pressure sores at their time of death. Furthermore, pressure sores were observed more often in underweight elderly in need of professional nursing care.

CONCLUSION

Underweight at the time of death is observed more often in the very old. This is associated with the need for professional nursing care and also the occurrence of pressure sores. Less than 5% of persons with tumors were included. The results underscore the need of early detection of people at risk of malnutrition when growing older.

Promotion of health in older people: a randomised controlled trial of health risk appraisal in British general practice

BACKGROUND

there is inadequate evidence to support currently formulated NHS strategies to achieve health promotion and preventative care in older people through broad-based screening and assessment in primary care. The most extensively evaluated delivery instrument for this purpose is Health Risk Appraisal (HRA). This article describes a trial using HRA to evaluate the effect on health behaviour and preventative-care uptake in older people in NHS primary care.

METHODS

a randomised controlled trial was undertaken in three London primary care group practices. Functionally independent community-dwelling patients older than 65 years (n = 2,503) received a self-administered Health Risk Appraisal for Older Persons (HRA-O) questionnaire leading to computer-generated individualised written feedback to participants and general practitioners (GPs), integrated into practice information-technology (IT) systems. All primary care staff received training in preventative health in older people. The main outcome measures were self-reported health behaviour and preventative care uptake at 1-year follow-up.

RESULTS

of 2,503 individuals randomised, 2,006 respondents (80.1%) (intervention, n = 940, control n = 1,066) were available for analysis. Intervention group respondents reported slightly higher pneumococcal vaccination uptake and equivocal improvement in physical activity levels compared with controls. No significant differences were observed for any other categories of health behaviour or preventative care measures at 1-year follow-up.

CONCLUSIONS

HRA-O implemented in this way resulted in minimal improvement of health behaviour or uptake of preventative care measures in older people. Supplementary reinforcement involving contact by health professionals with patients over and above routine clinical encounters may be a prerequisite to the effectiveness of IT-based delivery systems for health promotion in older people.

[Impact of fall risk and fear of falling on mobility of independently living senior citizens transitioning to frailty: screening results concerning fall prevention in the community]

PROBLEM

There is a strong relation between mobility, walking safety and living independently in old age. People with walking problems suffer from fear of falling and tend to restrict their mobility and performance level in the community environment--even before falls occur. This study was planned to test the validity and prognostic value of a fall risk screening instrument ("Sturz-Risiko-Check") that has already shown its feasibility, acceptance and reliability, targeting independently living senior citizens.

METHODS

The study sample was recruited from a sheltered housing complex in Hamburg (with written consent). Persons with need of professional care ("Pflegestufe" in Germany) were excluded. The residents were asked to fill in the multidimensional questionnaire ("Sturz-Risiko- Check"). In a second step, a trained nurse asked the participants in a phone call about their competence in the instrumental activities of daily living (I-ADL mod. from Lawton, Brody 1969) and about their usual mobility performance level (e.g. frequency and distance of daily walks, use of public transport). According to the number and weight of self-reported risk factors for falling, three groups: "low fall risk", "medium fall risk" and "high fall risk" were classified. Finally, this classification was re-tested after one year, asking for falls and fall related injuries.

RESULTS

A total of 112 senior citizens without need of personal care, living in a sheltered housing facility were asked to participate. Acceptance was high (76.1%). Self-reported data from 79 participants concerning falls, fall-risk, mobility and instrumental activities of daily living were included in the statistical analyses. Mean age was 78 (64 to 93) years and associated by a high percentage of women (75.9%) in this sample. The older participants reported 0 to 13 different factors (mean 5) related to a high risk of future falls. Most participants (78.5%) quit cycling because of fear of falling. There was a high incidence in the study sample and over the three risk groups of chronic disorders like cardiac failure (75.9%) and disturbed vision or hearing (64.6%). According to the rising risk of falling over the three risk groups (low, medium and high), there were symptoms of fast functional decline or frailty like diminished walking speed (6.3 vs 36.8 vs 72.0%), sarcopenia (failed chairrise test: 0 vs 18.4 vs 28%) or already perceived fall events (0 vs 5.3 vs 56.0%) and ongoing restriction in basic activities. Those results were proven by the data on fall frequencies after one year (follow-up). We found an increase in falls over all three risk groups (12.5 vs 31.6 vs 28%) with fall-related severe injuries (fractures) in two persons classified in the high fall-risk group.

DISCUSSION

The results of the fall-risk screening were useful to classify groups with different probability to fall in the near future. Fear-offalling and symptoms of frailty were related to an increasing risk of falling and loss of mobility and autonomy in still independently living senior citizens.

CONCLUSION

The fall-risk screening instrument ("Sturz-Risiko-Check" questionnaire) was useful and valid to predict risk of falling and functional decline in independently living senior citizens transitioning to frailty. This screening will be part of a prevention approach in the City of Hamburg to offer primary and secondary prevention interventions adapted to special target groups of community- dwelling elder people (robust in contrast to frail elderly). The implementation should be accompanied by training sessions for physicians in the primary care sector and health improvement programmes for elder citizens.

[Injury prevention as the physician's challenge]

In Germany, more than 9 million individuals yearly sustain injuries and more than 30,000 fatal injuries. Based on estimations, preventive measures could avoid more than one half of all accidents and could influence the other half of the accidents such that the injuries caused are minor. The aim of an initiative of the Study Group on Injury Prevention of the German Trauma Society (DGU) is a complete inventory of all prevention programs from different expert groups in Germany. A synopsis of the gathered knowledge should serve as a basis for further interdisciplinary preventive measures. The consistent interdisciplinary orientation of this program is a special characteristic including trauma surgery, orthopedics, pediatric surgery, pediatrics, sociology, legal medicine, psychology, sports medicine, geriatrics, anesthesiology, and others. Special attention was also directed to the age groups of children/adolescents and the elderly.

[What does the language of Alzheimer patients have to do with the language of Paul Celan?]

Being in touch with severely demented patients requires a fundamental transformation in communication habits in medicine and in nursing. There is a need of reorientation away from an interpreting and often deficit-oriented aspect of communication towards attentive observance of unusual verbal and nonverbal signals and resources of the patient. Spontaneous and open communication with the patient outweighs the importance of a goal-oriented exchange of information and poses a significant challenge for all health and social professions. The well-being of persons with dementia depends mainly on the quality of communication and on the design of the milieu and the quality of everyday life. Interaction in nursing seems to be the crucial issue, including both spontaneity and creativity in the interaction partners, while respecting the personal boundaries of both the patient and the nurse in the necessary intimacy of the care environment. This essay shows important aspects and strategies of adequate communication with people with dementia from the perspective of medicine and of nursing. Ways to improve communication skills are shown, referring, among others, to the approaches by Kate Allan and John Killick (research fellows at Dementia Services Development Centre, University of Stirling).

[Medicine in old age and in the elderly. Educational concepts in area Q7 of the accreditation requirements and its first evaluation by students]

Until very recently, medicine in old age was not an obligatory part of the medical students' education in Germany. This has been changed by an educational reform. However, there are no obliging recommendations or procedures on which issues of medicine in old age should be taught. Therefore, we describe the development of a new curriculum, first experiences with the teaching, and the results of its evaluation by the students at the University of Hamburg. As a result, the subjects and the didactic teaching were both well accepted by the students and judged as interesting and instructive.

High-grade decubitus ulcers in the elderly : A Postmortem Case-Control Study of Risk Factors

Some elderly persons develop high-grade decubitus ulcers, whereas others with comparable risk factors do not. In Germany, forensic pathologists are increasingly confronted by situations that necessitate an expert opinion on whether prevention of decubitus ulcers has been neglected in cases of suspected malpractice. This investigation was carried out in an attempt to identify risk factors for decubitus ulcers. We performed a postmortem case-control study in elderly persons who developed high-grade decubitus ulcers from 6 months to 14 days before death. Deceased with decubitus ulcers graded 3 or higher and controls at comparable risk were examined before cremation. After written informed consent had been obtained from the nearest living relatives, all available nursing and medical records of the deceased were thoroughly evaluated. Decubitus ulcer cases and controls were matched according to age, gender, immobility, and cachexia. One-hundred cases of decubitus ulcers with 71 grade 3 decubitus ulcers and 29 grade 4 decubitus ulcers were compared with 100 controls with 27 decubitus ulcers graded 2 or lower and the maximal risk as assessed by the Norton scale. The mean age was 86 years, 80% were females, 86% were bedridden, and cachexia was found in 66%. The individuals with decubitus ulcers were more often severely disabled, had more immobility of joints, and were more often under treatment with antidepressive and/or sedative drugs (e.g., opioid analgesies, neurolepties, benzodiazepines). Patients' impaired ability or unwillingness to comply or cooperate with preventive and therapeutic measures was more often recorded in cases of decubitus than in the control group. There was no evidence that supplementary nutrition or use of preventive pressure relief and protective devices differed between the decubitus cases and the controls.

Arzneimittelgebrauch und gesundheitliche Selbsteinschätzung selbstständig lebender, älterer Hamburger

Self-perceived health as reported by elderly persons is of prognostic value and corresponds with morbidity and mortality. In the present study, information about the utilisation of medication, visits to the doctor, and self-perceived health was provided by standardised self-reports. The study sample included 804 independent community-dwelling persons 60 years and older. These persons were recruited from the patient lists of 14 general practices in Hamburg. Exclusion criteria were dementive disorders and the need of personal care. On average, there were 3 prescribed drugs and 1 over-the-counter medication per person. The number of medications corresponds to a mean of 2 chronic disorders. Almost 50% of the participants reported suffering from pain, with more than one-third rating their pain intensity as moderate or high. Furthermore, nearly half of the study population stated their self-reported health as moderate or poor, and one-fifth reported symptoms of depressed mood. There were discrepancies between the reports of pain or depressed mood and the corresponding use of medication. It seems that self-reported symptoms and self-perceived health in elderly persons should be considered more often in drug prescribing.

[Fall events in geriatric hospital in-patients. Results of prospective recording over a 3 year period]

For a period of 3 consecutive years, all fall events were prospectively recorded in geriatric hospital in-patients by using a standardized protocol. The incidence was 9.1 fall events/1000 hospital days in 5946 patients, and 41.0/1000 hospital days in 1015 patients (17.0%) who actually had falls. The fall rate varied between 35.0-57.0/1000 hospital days according to the main diagnostic group. Fall events were more often recorded in men than women. Recurrent falls (> or =3 falls) which contributed 13% to the 1596 falls were recorded more frequently in male patients. The majority of fall events (73.5%) occurred in patient rooms, another 20% on the floor between the patient's bedroom and toilet/bath, or in the toilet/bath, respectively. The absolute numbers of falls during night and day were not different. However, there were different patterns in the time distribution of high fall frequencies according to the main diagnostic groups. Confusion and dehydration were recorded more frequently with fall events in patients 80 years and older, and more often in fall events during the night. Injuries due to falls which had to be treated were rare, and fall-related fractures were very rare. The average duration of in-hospital stay was longer for patients with than without falls.

Präventive Hausbesuche durch eine speziell fortgebildete Pflegefachkraft bei 60-jährigen und älteren Personen in Hamburg

There is increasing interest in home visits by phycisians, nurses or occupational therapists which offer health promotion or preventive care to older people. However, the practical performance of home visits, the targeting, and the effectiveness are ambigious. The collaboration in the EU-study 'disability prevention' gave the opportunity to recruit non-selected people 60 years and older from 14 general practitioners' patient lists in Hamburg. The study participants were offered different programs of health promotion, i. e., group sessions at the geriatric center and preventive home visits. The home visits were made by a nurse who received special training, and a curriculum was established. Seventy-seven elderly persons were visited because they were not able to attend the group sessions at the geriatric center due to self-reported problems in mobility. The investigations revealed combined risks for development of functional decline and dependency in the majority of these community dwelling elderly persons. These findings were unknown to the general practitioners. For example, the risk of falling as recorded by assessment was elevated in more than half of the persons visited. Screening and assessment are useful for planing measures of health promotion and prevention. There are still questions open to discussion. The targeting, practicability, and prerequisites in structure of service provision are considered with regard to the present study's results and an upto date literature review.

[Characteristics of hospitalized geriatric patients--a comparison of two cohorts using the screening of the Arbeitsgemeinschaft Geriatrisches Basisassessment (AGAST)]

The geriatric screening according to AGAST (Arbeitsgruppe Geriatrisches Basisassessment) contains functional and diagnosis related items, and risk indicators of prognostic relevance, particularly in hospitalized patients. In a retrospective, cohort study, we compared the screening results in 250 consecutive patients of geriatric in-hospital acute care, and 250 consecutive patients of geriatric in-hospital rehabilitation, as well as demographic characteristics, diagnoses, and functional status as measured by the Barthel index. There was a trend indicating the total number of positive screening findings being higher with older age. Positive correlations with age were found for hearing, leg function, and cognitive function in female patients. There were also associations between the frequencies of certain screening findings with diagnostic categories. Apart from the different official manner of admission to geriatric acute care or geriatric rehabilitation, there were differences between the cohorts in age, living place before hospitalization, discharge location, spectrum of diagnoses, and the degree of functional impairment. The screening results indicated that prognostic risk factors were not equally distributed among the study cohorts. These were, in particular, urinary incontinence, poor nutritional status, impaired cognitive function, and depressive mood. There were associations between risk frequency as indicated by the screening and complicated hospital stay, functional outcome, and death. Combined with additional data, the screening according to AGAST appears to be suitable for meaningful comparisons of different groups of geriatric patients.

[Knowledge concerning illness, expectations and perceptions of treatment of elderly stroke patients and family caregivers--a prospective study during inpatient treatment]

Forty-five stroke patients and their 45 proxies were interviewed after the patients' hospital admission and before discharge. The topics of the interviews were disease knowledge, expectations in and judgement about therapy, estimation of functional health status (CCOP/WONCA Charts), and prognosis. The patients and proxies were also asked to name the patient's actual three most important health problems. The depressive symptomatology in the patients (geriatric depression scale) and their ADL status (Barthel Index) were evaluated on admission and before hospital discharge. The proxies' general knowledge of disease was superior compared to that of the patients. There were knowledge deficits regarding individual risk factors and secondary prevention, in particular. Information was predominantly obtained from physicians. However, an additional need for information on prognosis and prevention, in particular, was expressed by patients and proxies before hospital discharge. There was a high agreement between the patients and their proxies in mentioning the patients' actual three most important health problems, apart from psychological problems. These were mentioned only by the proxies but not by the patients themselves. Depressive symptomatology in the patients increased significantly. There were associations of depression with the level of the Barthel Index score and the patients' self-estimation of functional health status before and after the stroke. Full recovery was expected by one half of the patients, on admission. The patients' primary therapeutic goal was the ability to walk again. Their ADL status improved significantly, as measured by a mean increase in the Barthel Index score by 22 points. The patients and their proxies, as well, judged the result of treatment equally high. The proxies' total satisfaction with patient care was significantly related to their ratings of separate parts of patient care regarding nurses, therapists, and physicians, to their expectations in therapy, and the satisfaction of their own personal needs. The results of the study revealed a particular need for information on prognosis and secondary prevention of stroke. Furthermore, depression and coping with consequences of the disease should be important issues in counselling of stroke patients and their proxies. The results regarding patient and proxy satisfaction with care were of importance for internal discussion in the clinic.

Predictors of favorable outcome in elderly stroke patients two years after discharge from geriatric rehabilitation

This study was done to determine the independent predictors of long-term survival and long-term functional outcome in geriatric stroke patients with a high level of co-morbidity. We prospectively recruited 302 consecutive patients transferred from local hospitals of acute care to inpatient geriatric rehabilitation with a median of 23 days after stroke. The cohort with a mean age of 75.1 (range 60-90) years was followed up for 2 years after discharge from rehabilitation. The 24 month survival rate was 71.2%. Urinary continence (p = 0.000), younger age (p = 0.000), and absence of coronary artery disease (CAD) (p = 0.039) were predictors of survival. Independence in activities of daily living (Barthel Index (BI) > or = 85) 24 months after discharge was 43.2% and predicted by an admission BI > or = 50 (p = 0.000), urinary continence (p = 0.007), and absence of CAD (p = 0.018). Good functional outcome by the Modified Rankin Scale (MRS < or = 3) 24 months after discharge was 38.4%. It was predicted by absence of CAD (p = 0.001), first-ever stroke (p = 0.014), admission BI > or = 50 (p = 0.024), urinary continence (p = 0.025), mild motor paresis (p = 0.032), and good sitting balance (p = 0.039). Our study of a relatively aged and co-morbid stroke cohort confirmed most of the well-known predictors of outcome. A new result is that CAD also seems to be an important determinant of long-term outcome.

[Epidemiological aspects of morbidity in the elderly]

The spectrum of morbidity in older age is dominated by chronic diseases. Higher age is associated with functional difficulties, limitations, and disability. However, inter- and intraindividual variability is wide. Sequela of chronic diseases are crucial to the development of dependency and the use of health care. They are cost intensive. The number of very old people will particularly increase according to estimations of future demographic changes in Germany. It can, thus, be assumed that the need for geriatric care, specific prevention and rehabilitation will not decrease soon.

[Quality assurance in geriatric medicine]

This article describes the peculiarities of geriatric quality assurance from the view of a clinical setting. Description of structural elements of quality are well known. Improvements in process quality of individual patient care have been sustained by controlled studies on comprehensive geriatric assessment. However, implementation of results from comprehensive assessment into external rating systems for hospital accreditation/certification still needs further research. The documentation of product quality depends on the measurement of patients' independency, activities of daily living and subjective well being.