Direct health care costs of managing perianal Crohn's Disease in a population based cohort.

BACKGROUND: Crohn's disease is a chronic condition that places a high health care cost burden. Perianal Crohn's disease (pCD) is a difficult phenotype to treat due to poorer response to medical and surgical therapies. No study has assessed if this translates to higher healthcare costs. The aim is to assess the cost of treating pCD and compare to the cost of non-perianal Crohn's disease (CD). METHODS: This is a retrospective case-control cohort study in a population-based setting. The direct healthcare costs for patients with pCD were calculated over 12 months. Data was compared to the control group of non-perianal CD patients on biologic treatment, with the use of the Mann-Whitney rank test to assess significance. RESULTS: 187 Crohn's patients were included (39 pCD, 148 CD). Per patient, annual cost was €17,779.19 and €17,576.86 respectively (p = .9391). Medications were responsible for the majority of cost at 78% and 92% of total cost in pCD and CD, respectively (€13,886.04 in pCD, and €16,007.10 in CD), of which biologics were the main driver. Surgical costs were higher in the pCD group due to a higher cost of luminal surgery (€2633.88 in pCD vs €209.79 in CD, p = .0270). CONCLUSION: This is the first study to assess the cost of treating perianal Crohn's disease in a real-world population. Although the costs were similar overall to non-perianal Crohn's patients, the perianal cohort had higher surgical costs from luminal surgery. This demonstrates the potential to apply early intensive treatment to reduce future surgical cost.

Crohn's disease is a lifelong disease where high-cost drugs are required to achieve optimal outcomes. There is minimal data regarding the cost of managing perianal fistulising Crohn's disease and whether the clinical complexity of these patients translates to higher healthcare costs. Costs were similar between luminal Crohn's disease patients treated with a biologic and those with perianal disease, though the distribution of costs varied. Knowing this distribution will allow for more effective allocation of resources.

[Humor therapy in the depressed elderly: results of an empirical study]. / Humortherapie bei alten Menschen mit einer Depression: Ergebnisse einer empirischen Untersuchung.

BACKGROUND: Positive effects of humor on older patients with depressive symptoms have been repeatedly reported. Empirical evidence, however, is rare. We investigated the effects of a standardized humor therapy group in a clinical context especially for older depressed patients. PATIENTS AND METHODS: For this purpose, an experimental group with treatment (52 patients participating in the humor group) was compared to a control group with no specific treatment (38 patients); all 90 participants had clinical depressive symptoms according to ICD-10 classification. Questionnaires (among them GDS, SF-12, State-Trait Cheerfulness Inventory, Satisfaction with Life Scale) were administered at two time points (pre- and post-treatment). RESULTS: From pre- to post-measurement, significant improvements could be shown only in the experimental group for resilience and satisfaction with life (p<0.05). Analyses of the subgroups with at least medium to severe depression showed further significant effects for cheerfulness, seriousness, bad mood, and satisfaction with life (p<0.05). These severely affected patients seemed to profit best from humor therapy. CONCLUSION: Our results indicate the efficacy of this specific therapeutic intervention for older depressed patients.

[Causes of death in nursing homes--a retrospective autopsy study]. / Todesursachenspektrum im Altenheim im Spiegel eines rechtsmedizinischen Sektionsgutes.

Autopsies from 34 fatalities in nursing homes covering a 10-year period (1991-2000) were retrospectively analyzed with regard to criminal investigative issues, causes of death and relevance of the forensic medical findings for the outcome of the criminal investigations. The material consisted of 22 females and 12 males, with the ages ranging from 62 to 102. The allegations to be investigated comprised wrongful death, improper nursing, medical maltreatment, suspicion of poisoning and the causal relationship between falls and the occurrence of death. The manner of death, respectively cause of death encountered included 21 deaths from natural cause (coronary insufficiency, pneumonia), 9 accidental deaths (hypothermia, choking, scalding burns and injuries due to fall) and 4 cases which remained undetermined. In 30 out of 34 cases, the cause of death was unequivocally established. In every case, the medicolegal investigation provided adequate evidence for the legal assessment. Of particular significance was the exclusion of a causal relationship between falls and the occurrence of death. Without exception, all investigations failed to uncover criminal causes for death in this sample.

[Pharmacotherapy of patients with dementia]. / Pharmakotherapie bei Menschen mit Demenzerkrankungen.

Dementing illnesses present among the most frequent and most consequential psychiatric disorders in old age. They thus constitute a particular challenge for science politics and society as a whole. Knowledge about multifactorial etiological and pathological factors is still rather limited. By way of stratified diagnostic procedures various dementia disorders can be differentiated rather reliably. Anti-dementia drugs can enhance cognitive performance and temporarily slow down the progress of the most frequently occurring dementias (Alzheimer-dementia, vascular dementia). In the treatment of behavioral symptoms in dementia newly developed psychopharmological agents are of particular relevance. They constitute an important element of a multi-modal therapeutic strategy.

[Sexual activity in old age-problem-oriented counselling from the psychiatric point of view]. / Sexualität im Alter-Problemorientierte Beratungspraxis aus psychiatrischer Sicht.

Empirical investigations often report sexual activity in old age. Society's negative stereotype of the aging person, however, results in the topic being socially taboo and prejudiced. Active sexual intercourse gets less frequent in advancing age, but masturbation and sexual fantasies still prevail. In higher age groups men are seemingly more active than women. Persons living inconstant partnerships are more active than persons living on their own. There is a significant shift from sexual intercourse to tenderness, confidence, and satisfying relations. There are numerous physical, psychological, and social factors influencing sex life in old age. Important physiological alterations and their consequences are to be observed in advancing age. Multiple diseases, drugs, and objective and subjective (e.g. anxiety disorders) after-effects of operations often result in reducing or totally giving up sexual activities. If a doctor has hints pointing to sex problems these ought to be talked about without any prejudice and with an intention of looking for possible solutions. Frequently these problems are indicative of psychological or functional disorders which may respond to a treatment by competent counselor or psychotherapist.

[Socio- and psychotherapy in patients with Alzheimer disease]. / Sozio- und Psychotherapie bei Alzheimerkranken.

Symptoms presented by patients with Alzheimer-type dementia do not only reflect organic disturbances only but require a holistic and person-oriented view. Affective and behavioral disturbances are not necessarily secondary to cognitive impairment. Guidelines are presented for a multidimensional treatment involving the significant other. Socio- and psychotherapy are essential for this treatment. Their approaches have greatly increased in number and diversity in the past few years. Sociotherapy is based on milieu therapy and includes different training- and group activities. Several psychosocial treatment modalities are available, including validation, dementia care mapping, reminiscence therapy, cognitive training and psychoeducational group work. Psychotherapeutic approaches include relaxation techniques, and psychodynamic oriented- and behavioral modalities. The indication for a specific modality is based on an assessment of the disturbances present and available resources. Of special importance are also services to family carers, including counseling, psychotherapy, as well as support and modification of the care-setting. Even though there are only limited empirical data available on the effects of socio- and psychotherapy for patients with Alzheimer-type dementia, the available evidence is indicative of a positive influence on symptoms of this illness. Diversity of symptoms and individualized, variable course of the illness may point to the importance of psychological and social factors in this illness, by far larger than presently recognized.

[Violence against the aged within the family: results of studies by the "Bonner HsM (treating vs. mistreating) Study]. / Gewalt gegen alte Menschen in der Familie: Untersuchungsergebnisse der "Bonner HsM-Studie".

Central aspects of intra-familiar violence and of their causes are discussed. The first results of the study "Handeln statt Misshandeln" (HSM, Action against Violence) are presented. Data were collected in Bonn, Germany, by the means of a postal questionnaire. Approximately 10 percent of old people reported experiences of violence in their families during the past five years. Most often mental violence and financial deceit were mentioned. Experiences of violence mainly caused psychological and emotional problems. If at all, victims searched for support in their immediate social network. Persons who were married or of bad physical health had often experiences of violence. Significant difference between victims and non-victims were detected for experiences of violence, the victims' subjective well-being, the quality of the families' external relations and the victims' socio-economic status.

[The "restraint" controversy in geriatric psychiatry. Focus study of factors influencing restraint measures]. / Problemfeld "Fixierung" in der Gerontopsychiatrie. Stichtagserhebung über Einflussfaktoren bewegungseinschränkender Massnahmen.

The study examines the relationship between frequency and duration of restraints in psychogeriatric inpatients with their respective diagnosis, medication, reason for restraints, and age as a socio-demographic variable. Entered in the analysis were data from 590 inpatients from a total of 29 institutions within the Federal Republic of Germany psychogeriatric facilities; this was 24.7% of all psychogeriatrically treated inpatients on the survey day in the said 29 institutions. The data were analyzed via simple multifactorial analyses of variance followed by multiple classification analysis (SPSS for Windows). Neither age nor diagnosis showed any differential influence on frequency or duration of restraints. Among the reasons for restrains hetero-aggression led to fewer and shorter restraints; self-aggression led to fewer but longer restraints. Restless patients were restrained more often but for shorter intervals. The main psychopharmacological strategy, while having no influence on the frequency of restraints, showed a marked influence on their duration; patients treated with low potent neuroleptics had particularly short intervals of restraints, whereas patients free from psychopharmacological agents showed distinctly longer intervals of restraints than the mean of restrained patients.

[Medical graduate and continuing education in gerontopsychiatry and psychotherapy]. / Arztliche Weiter- und Fortbildung in der Gerontopsychiatrie und -psychotherapie.

Continuous medical training in psychogeriatrics and in psychotherapy with the elderly is in need of improvement in many respects. There are, however, manyfold efforts to theoretically and practically mediate the state of the art in the course of medical further training. We present a model of psychiatric and psychotherapeutic care for the elderly in continuous medical training which is already a basic component in many psychiatric training facilities, aimed at providing each and every board certified psychiatrist and neurologist with adequate psychogeriatric competency. Growing knowledge in this field doubtlessly requires the development of a respective academic sub-specialty. Training facilities not only for psychiatrists, psychotherapists, and neurologists, but also for various other medical disciplines, in particular for general practitioners, as well as for nonmedical professionals in the field of care for the elderly have increased in recent years. As an example we point to the Gerontological Forum.

[Psychiatry and psychotherapy of aging]. / Psychiatrie und Psychotherapie des Alterns.

The competence model is fundamental for the understanding of the aging process. This model does not limit itself to a description of deficits but focusses on the existing skills and capabilities of the person, allowing for age related pecularities. All geropsychiatric interventions start from a geropsychiatric assessment which extends beyond medical diagnosis and an enumeration of findings. This requires interdisciplinary cooperation. Since psychiatric illness in old age has multiple determinants, interventions need to embrace multidimensional approaches on the somatic, psychological and social level. At present, a number of interventions are available for treatment, rehabilitation and nursing care of old people with psychiatric illness. This includes psychotherapeutic interventions, which have proven successful. A reductionists view is therefore not warranted. An appropriate level of care, including rehabilitation or skilled nursing care, for the elderly from a high risk group for psychiatric morbidity or with psychiatric illness already present requires coordination of regional care facilities.

[Balint groups in psychotherapy of elderly patients]. / Balintgruppen in der Altenarbeit.

Care of the elderly is typified by the relationship: elderly client/patient--younger helper/therapist. In Balint groups, relationships in interpersonal interactions are examined. This leads to a "patient-oriente" view and enables the participants to formulate a "comprehensive diagnosis". Multi-professional "gerontological"-Balint groups reduce reciprocal prejudices and value-judgements and promote cooperation between professional groups, further the understanding of the elderly in need of care, as well as the formulation of a patient-oriented "comprehensive treatment plan". By including creative productions in the Balint-group process, unconscious determinants of disturbed interpersonal relationships can be made "visible".

[Report on professional workshops "Aging and psychotherapy"]. / Bericht über die Arbeitstagungen "Alter und Psychotherapie".

Since 1989, annual scientific meetings "Age and psychotherapy" have been held in Erlangen, and since 1991, in Bonn. For each meeting a special topic has been selected such as, "Multimorbidity and Psychotherapeutic Implications," "Dementia and Psychotherapy," "Sexuality and Partnership." In addition to scientific papers related to the topic, courses, seminars and workshops have been offered since 1992 to exchange practical knowledge about psychotherapy with the elderly (e.g., autogenic training, family work, Balint-group, family therapy, art therapy, psychotherapy in psychogeriatrics, self-experience workshop, assertiveness-training, supervision). In addition to advanced training and continuous education, the main objective of these meetings has been to offer a forum to share knowledge and experience with professionals working in psychotherapy with the elderly.

[Autogenic training in gerontology]. / Das Autogene Training in der Gerontologie.

Autogenic Training (AT) is the most common method of psychotherapy in use today. It is however rarely used with older people who are generally considered less responsive to this method. In this analysis we consider whether or not this scepticism is justified. Our control group consisted of 58 subjects who learnt AT in 7 one-and-a-half-hour sessions. The age of the subjects of two groups was between 18 and 54 years ("younger group") and that of the other two groups between 58 and 80 years ("older group"). 77% of all the subjects were able to get a sufficient grasp of AT over this period. There were no statistically significant differences between young and old in the level of success attained in the individual exercises. It can be proved that the more elderly are more strongly motivated to learn AT and to integrate it into their daily lives. The group situation also meets the greater need of the elderly for contact and mutual support. The results of this small random test should show the way ahead for future investigations necessary in this area.

Histographic surgery: accuracy of visual assessment of the margins of basal-cell epithelioma.

In 72 basal-cell epitheliomas, the clinical extension and the actual extension of the defect measured by complete tumor removal by Mohs' chemosurgery were compared. Subclinical extension depends on the type of basal-cell epithelioma (primary, recurrent), on case history, location, clinical diameter, number of previous treatments and histological type. It is remarkably great in large (diameter more than 20 mm), in morphea-like basal-cell epitheliomas on the forehead, temple and scalp, especially following several previous treatments. In such cases the excision should include at least a 5-10 mm margin of "normal tissue." Present results again show that "histographic," that is, Mohs' chemosurgery is the method of choice for the treatment for these tumors.