[Diabetes care and incidence of severe hypoglycemia in nursing home facilities and nursing services: The Heidelberg Diabetes Study]. / Behandlungsqualität des Diabetes mellitus und Inzidenz schwerer Hypoglykämien in stationären und ambulanten Versorgungseinrichtungen: Heidelberger Diabetesstudie.

AIM: The goal of this study was to perform a structured analysis of the treatment quality and acute complications of geriatric patients with diabetes mellitus (DM) cared for by nursing services and nursing home facilities. Secondly, structural problems and potentials for improvement in the care of multimorbid older people with DM treated by nursing homes and nursing services were analysed from the viewpoint of geriatric nurses, managers of nursing homes and general practitioners. METHODS: In all, 77 older persons with DM from 13 nursing homes and 3 nursing services were included in the analysis (76.6% female, HbA1c 6.9 ± 1.4%, age 81.6 ± 9.9 years). Structural problems and potentials for improvement were collected from 95 geriatric nurses, 9 managers of nursing homes and 6 general practitioners using semistandardized questionnaires. RESULTS: Metabolic control was too strict in care-dependent older people with DM (mean HbA1c value: 6.9 ± 1.4 %; recommended by guidelines: 7-8%). The measurement of HbA1c was performed in 16 of 77 people (20.8%) within the last year despite a high visitation frequency of the general practitioners (12.7 ± 7.7 within the last 6 months). The incidence of severe hypoglycemia was 7.8%/patient/year. Regarding the management in case of diabetes-related acute complications 33 geriatric nurses (34.7%) stated not having any written standard (nursing home 39%, geriatric services 16.7%). CONCLUSION: Complex insulin therapies are still used in older people with DM with the consequence of a high incidence of severe hypoglycemia. Concrete management standards in the case of diabetes-related acute complications for geriatric nurses are lacking for more than one third of the nursing services.

Safety and immunogenicity of a quadrivalent meningococcal conjugate vaccine (MenACYW-DT): a multicenter, open-label, non-randomized, phase III clinical trial.

OBJECTIVE: To assess the safety and immunogenicity of a quadrivalent meningococcal (groups A,C,Y,W) polysaccharide diphtheria toxoid conjugate vaccine (MenACYW-DT) in India. DESIGN: Open-label, descriptive, non-randomized study. SETTING: Three medical college hospitals, one each in New Delhi, Bengaluru and Mumbai, India. PARTICIPANTS: 300 healthy, vaccine-naïve participants (100 children aged 2-11 years, 100 adolescents aged 12-17 years, and 100 adults aged 18-55 years). INTERVENTION: One dose (0.5 mL) of MenACYW-DT administered intramuscularly. MAIN OUTCOME MEASURES: Serum bactericidal antibody titers against A, C, Y, and W were measured before and after MenACWY-DT vaccination. Safety data were also collected. RESULTS: Thirty days post-vaccination, geometric mean titers rose across all serogroups. Most participants had protective titers >8 (1/dil) across the four serogroups. The percentage (95% CI) achieving >8 (1/dil) in the Adolescent Group was typical - A: 96.9% (91.2%; 99.4%); C: 96.9% (91.2%; 99.4%); Y:100% (96.3%; 100%); W:100% (96.3%; 100%). In general, solicited reactions were mild and short-lived. Unsolicited events were uncommon and unrelated to vaccination. CONCLUSIONS: MenACYW-DT was well tolerated and elicited a robust and protective immune response 30 days post-vaccination against meningococcal serogroups A, C, Y, and W-135 in the Indian study participants aged 2-55 years.

[Diabetes and dementia]. / Diabetes und Demenz.

Diabetes mellitus is a known risk factor for cognitive dysfunction and dementia. Chronic hyperglycemia, genetic predisposition, arterial hypertension, hyperlipoproteinemia, micro- and macrovascular diseases, and depression play a major role in the development of cognitive dysfunction. Both pathophysiology of diabetes and dementia and the specifics of diabetes therapy in patients with dementia are presented in this review.

[Acute illness and depression in the elderly and the influence of cognitive impairment : AIDE-cog trial]. / Komorbidität von Depression und Demenz bei geriatrischen Patienten mit akuter körperlicher Erkrankung: AIDE-cog-Studie.

Geriatric patients with acute somatic illness have a high comorbidity of depression and dementia. The following differential diagnoses have to be discerned: pseudodementia in acute depressive states, depression as a risk factor for dementia, and a depressive episode in the early stage of dementia. For both the symptoms and the trigger factors of these differential diagnoses the overlap and the particularities were qualitatively examined in the AIDE-cog (Acute Illness and Depression in Elderly cognition) trial. A second prospective randomized controlled part of the AIDE-cog trial quantitatively evaluated the influence of cognitive impairment in geriatric patients with an acute somatic illness and comorbid depression on the therapeutic effect of cognitive behavioral therapy. A preliminary analysis shows that already in early dementia the therapeutic effects are inferior. Other psychotherapeutic methods that address the remaining cognitive and emotional functions in dementia must be evaluated.

[Palliative care for patients with dementia]. / Palliativversorgung von Menschen mit Demenz.

Patients with dementia are an important target group for palliative care since particularly in advanced stages and at the end of life they often have complex health care and psychosocial needs. However, people with dementia have inappropriate access to palliative care. So far, palliative care focuses on cancer patients. Among other reasons, this is due to the different illness trajectories: while in cancer a relatively clear terminal phase is typical, in dementia functional decline is gradual without a clear terminal phase, making advanced care planning more difficult. Good communication among health care providers and with the patient and his/her family is essential to avoid unnecessary or even harmful interventions at the end of life (e.g., inserting a percutaneous endoscopic gastrostomy, PEG). To maintain the patient's autonomy and to deliver health care according to the individual preferences, it is important to appropriately inform the patient and the family at an early stage about the disease and problems that may occur. In this context, advanced directives can be helpful.

[Diabetes and cardiovascular diseases in old age]. / Diabetes und kardiovaskuläre Erkrankungen im Alter.

The treatment of cardiovascular diseases in diabetic geriatric patients needs an individual risk-benefit analysis. The overtreatment of hyperglycemia in the sense of metabolic control that is too tight (HbA(1)c level <6%) may lead to increased mortality. As a rule, the target HbA(1)c level in geriatric patients with diabetes mellitus should be between 7 and 8%.

[Palliative geriatrics. What are the differences between oncologic and non-oncologic palliative geriatric inpatients?]. / Palliative Geriatrie. Wie unterscheiden sich onkologische von nichtonkologischen geriatrischen Palliativpatienten im Krankenhaus?

AIM OF THE STUDY: Analysis of differences between oncologic and non-oncologic patients in the first German hospital-based special care unit for palliative geriatrics. METHODS: Systematic analysis of patients' records according to a standardized protocol. RESULTS: A total of 217 patients from a hospital-based special care unit for palliative geriatrics (56.7% women, 43.4% men) were included over a retrospective period of 1.5 years. Patients were categorized as non-oncologic (53.4%, n=116) or oncologic (46.5%, n=101). Non-oncologic patients were older than oncologic patients (84.0 vs. 76.8 years, p=0.02), and showed a higher degree of functional dependence (p<0.001) and mortality (87.1% vs. 53.3%, p<0.001). The two most common non-oncologic categories of primary diagnoses were pulmonary and neurologic diseases: 19% each. Certain secondary diagnoses had a higher incidence with non-oncologic than oncologic patients, such as pulmonary disease (39% vs. 24%, p=0.02) and dementia (38% vs. 8%, p<0.001). The Charlson comorbidity index was found to be higher for oncologic patients than for non-oncologic patients (6.6 vs. 4.1, p=0.001). Non-oncologic patients also experienced more dysphagia (57% vs. 17%, p<0.001), NPO (43% vs. 12%, p<0.001), and tube or parenteral feeding (31% vs. 9%, p=0.001). Oncologic patients experienced more often symptoms of pain, constipation, agitation, diarrhea, vomiting, and nausea. CONCLUSION: There are clinically relevant differences between oncologic and non-oncologic palliative geriatric inpatients regarding the constellation of symptoms, care, mortality, and the prevalence of concerns about hydration and feeding. These differences ought to be taken into account for further education, as well as further improvement of the healthcare system, to enable an appropriate standard of palliative care for geriatric patients.

[Treatment quality in geriatric patients with diabetes mellitus in various home environments]. / Behandlungsqualität bei geriatrischen Patienten mit Diabetes mellitus in verschiedenen häuslichen Versorgungsstrukturen.

OBJECTIVE: The goal of the present study was to systematically assess treatment quality, perceptions, and cognitive function of elderly patients with diabetes admitted to an acute geriatric hospital from different home environments (nursing home residents, home care, assisted living, family caregivers, self-sufficient). METHODS: Quality of diabetes treatment, metabolic control (HbA(1c)), nutrition, treatment satisfaction, cognition, disability, and level of dependency were assessed in 128 patients with diabetes. RESULTS: Out of 128 patients, 87 patients (68%) showed an HbA1c≤8% according to the guidelines for aging people with diabetes of the German Diabetes Association (DDG). Compared to patients living independently at home, the metabolic control in nursing home residents and their treatment satisfaction were as good. They had a higher degree of dependency though (Barthel, p<0.001), more strongly impaired mobility (Tinetti, p<0.01), less diabetes knowledge (p<0.001), inferior cognitive performance (MMSE, SPMSQ, p<0.01), and a higher prevalence of depression (GDS) (p<0.01). Better cognitive function correlated with better diabetes knowledge (r=0.49; p<0.001), but not with better metabolic control. CONCLUSION: The treatment of geriatric patients with diabetes mellitus requires individual considerations and interdisciplinary care. Particularly the continuing education of geriatric nurses could contribute to improved diabetes treatment quality in nursing home residents.

Repressive coping in geriatric patients' reports - impact on fear of falling.

We investigated the influence of repressive coping, depression, cognition, education and age on geriatric patients' reports on health-related status in 80 geriatric patients with a history of injurious falls. For patient reports, subjective statements on activity avoidance, perception of terminal decline, falls, and fear of falling were assessed. Co-morbidity and number of medications were documented based on patient charts. Repressive coping was significantly associated with underreporting in geriatric patients in all items documented and predicted most variables of patients' reports. Because of underreporting significant health problems geriatric patients with repressive coping may therefore be at risk for inadequate medical treatment.

Phase II meningococcal B vesicle vaccine trial in New Zealand infants.

BACKGROUND: A tailor-made serogroup B outer membrane vesicle vaccine was evaluated in the context of a serogroup B meningococcal epidemic dominated by Neisseria meningitidis strain B:4:P1.7b,4. OBJECTIVE: To determine the safety, reactogenicity and immunogenicity in infants aged 6-8 months of a meningococcal B vaccine developed against the New Zealand epidemic strain. DESIGN, SETTING AND PARTICIPANTS: Observer-blind, randomised, controlled trial conducted in 296 healthy infants in Auckland, New Zealand. INTERVENTION: Infants were randomised 4:1 to receive three doses of New Zealand candidate vaccine (epidemic strain NZ98/254, B:4:P1.7b,4) or meningococcal C conjugate vaccine at 6-weekly intervals. MAIN OUTCOME MEASURES: Immune response was determined by human complement mediated serum bactericidal assay. Sero-response was a fourfold or greater rise in titre compared to baseline, with baseline titres <4 required to increase to >or=8. Blood samples were taken before vaccination, 6 weeks after dose two, and 4 weeks after dose three. Local and systemic reactions were recorded for 7 days following vaccination. RESULTS: Sero-response to the candidate vaccine strain, NZ98/254, was demonstrated in 74% of vaccinees (95% CI: 68% to 80% intention-to-treat; 67% to 79% per protocol) after three doses of New Zealand candidate vaccine. No meningococcal C conjugate vaccine recipients were sero-responders to NZ98/254 after three doses. Both vaccines were well tolerated with no vaccine related serious adverse events. CONCLUSIONS: Our data indicate that the New Zealand candidate vaccine administered in three doses to this group of 6-8-month-old infants was safe and immunogenic against the candidate vaccine strain NZ98/254 (Neisseria meningitidis B:4:P1.7b,4).

Designing studies on the effectiveness of physical training in patients with cognitive impairment.

The literature provides conflicting results on the effectiveness of physical training in cognitively impaired older individuals. Cognitive impairment has been shown to be a negative predictor of rehabilitation outcome in these persons. However, the evidence on which this discussion is based is scarce. The methodology used in previous studies shows substantial shortcomings. The presented study protocol documents the methodology of one of the largest intervention studies worldwide in this research field with a standardized specific training program in cognitively impaired subjects including short- and long-term follow-up examinations. The selected sensitive evaluation tools for motor, cognitive and emotional status have all been validated for use in older persons. Most of these tests have been validated in cognitively impaired persons. In contrast to most previously published RCTs only study participants within a comparable level of cognitive impairment will be included in the study. The primary aim of the study is to evaluate a specific training program to improve motor performance (strength and functional performance) in persons with cognitive impairment. Secondary study endpoints include the reduction of falls, improvement of cognitive as well as psychological status and the documentation of physical activity. The training program is based on previous successful intervention studies of the research group, was complemented and modified with respect to specific deficits of cognitively impaired persons and focuses on motor improvements. The article gives a rationale for interventions using physical training and study methodology in persons with dementia.

[Complaints under analgesics: the difficult interpretation by older patients]. / Beschwerden unter Analgetika: Uber die schwierige Interpretation bei älteren Patienten.

BACKGROUND: Older patients, particularly those with multimorbidity, complain about many symptoms which also occur under analgesics (especially with opioids). The goals of the study were to quantify symptoms and discuss the relationships to analgesics, pain, multimorbidity, function, age and gender. PATIENTS AND METHODS: On admittance to geriatric hospital, 1700 consecutive inpatients were questioned about symptoms typically of side-effects of analgesics and pain. Additionally medication including analgesics, activities of daily living, orientation, age, gender and morbidity were recorded. RESULTS: Of the patients, 1,418 (mean age 80.9 years) could answer questions about symptoms. Disturbance of sleep (n=664, 46.8%), pain (n=609, 43.0%), low appetite (551, 37.4%), dizziness (482, 34%), tiredness (331, 19.7%), constipation (236, 16.6%) and problems of urination (213, 12.7%) were indicated most frequently. Univariate analysis showed the well known correlations of analgesics and symptoms to be dependent on dose and substances. However, using a multivariate model, analgesics lost the significance for the symptoms with some exceptions. Pain intensity, duration of pain and gender differences became more important. Vomiting, dry mouth, and problems with urination correlated with low levels of activities of daily living. Increasing morbidity and cognitive deficits were not important for many symptoms. CONCLUSIONS: Our results underline the difficult interpretation of symptoms as a side-effect of analgesic treatment in older patients. Pain and gender differences have to be considered. The recommendation to carefully record symptoms before analgesic treatment is supported by our results.

[Situation of nursing home residents with continence problems: a study in two German nursing homes]. / Die Situation von PflegeheimbewohnerInnen mit Kontinenzproblemen: eine Studie in 2 deutschen Pflegeheimen.

AIM OF THE STUDY: To describe the situation of residents with continence problems (CP) in two German nursing homes. METHODS: Medical and nursing records of all residents were reviewed and categorised according to a standardised protocol. Structured interviews were performed with the responsible nursing staff of each resident. Qualitative methods like focus groups and participating observations were used to collect further information. RESULTS: In the investigated nursing homes 177 residents with and 70 without CP were identified (81.5% women; mean age 83.7 years). For these 247 residents 57 physicians and 116 nurses or nurses-aides were in charge. 71% of female and 76% of male residents had at least one CP. The three most common CP among residents were combined urinary and faecal incontinence (32%), urinary incontinence (21%), and urinary catheters (17%). Residents with CP were significantly more dependent in functional abilities like toileting, dressing or cognitive function than those without CP (P<0.01). In a high proportion of residents with CP physicians (64%) were not consulted nor were relatives (86%) involved in continence related activities. CONCLUSION: Nursing home residents are commonly affected by continence problems which are associated with functional dependency and relevant co-morbidity. The public and expert debate on continence problems of nursing home residents has to be promoted to achieve long-term changes.

Combined administration of serogroup B meningococcal vaccine and conjugated serogroup C meningococcal vaccine is safe and immunogenic in college students.

This study evaluated the first use of a combination of the lyophilized components of the conjugated group C vaccine Menjugate reconstituted with the liquid group B outer membrane vesicle (OMV) vaccine MeNZB. At 6-week intervals, healthy residential students received three doses of MeNZB alone or concomitantly with one dose of Menjugate (MeNZB+MenC). Short-lasting injection-site reactions of mild or moderate intensity were frequent in both groups. There were no vaccine-related serious adverse events. After three doses, the percentage of subjects with serum bactericidal assay (SBA) titres > or = 1:8 against the serogroup B strain NZ98/254 was 82% for MeNZB+MenC and 78% for MeNZB. All subjects in the MeNZB+MenC group achieved SBA titres > or = 1:8 against serogroup strain C11 and 67% in the MeNZB group. All SBA and ELISA responses of the combined vaccine were at least as good as for MeNZB alone. After vaccination, the pharyngeal carriage rate of any meningococcus in the vaccinated group had declined from 40% to 21%.

Prolonged activation EEG differentiates dementia with and without delirium in frail elderly patients.

OBJECTIVE: Delirium in the elderly results in increased morbidity, mortality and functional decline. Delirium is underdiagnosed, particularly in dementia. To increase diagnostic accuracy, we investigated whether maintenance of activation assessed by EEG discriminates delirium in association with dementia (D+D) from dementia without delirium (DP) and cognitively unimpaired elderly subjects (CU). METHOD: Routine and quantitative EEG (rEEG/qEEG) with additional prolonged activation (3 min eyes open period) were evaluated in hospitalised elderly patients with acute geriatric disease. Patients were assigned post hoc to three comparable groups (D+D/DP/CU) by expert consensus based on DSM-IV criteria. Dementia diagnosis was confirmed using cognitive and functional tests and caregiver rating (IQCODE, Informed Questionnaire of Cognitive Decline in the Elderly). RESULTS: While rEEG at rest showed low accuracy for a diagnosis of delirium, qEEG in DP and CU revealed a specific activation pattern of high significance found to be absent in the D+D group. Stepwise logistic regression confirmed that differentiation of D+D from DP was best resolved using activated upper alpha and delta power density which, compared with rEEG, enabled an 11% increase in diagnostic correctness to 83%, resulting in 67% sensitivity and 91% specificity. Among frail CU and D+D subjects, almost 90% were correctly classified. CONCLUSION: Dementia associated with delirium can be discriminated reliably from dementia alone in a meaningful clinical setting. Thus EEG evaluation in chronic encephalopathy should be optimised by a simple activation task and spectral analysis, particularly in the elderly with dementia.

[3rd Workshop on Epidemiology, Prevention and Treatment of Invasive Meningococcal Disease in Würzburg 2006]. / 3. Würzburger Workshop zur Epidemiologie, Prävention und Therapie der invasiven Meningokokkenerkrankung 2006.

On October 5th, 2006, the German Reference Centre for Meningococci (NRZM) held the 3rd Workshop on Epidemiology, Prevention and Treatment of Invasive Meningococcal Disease, in collaboration with the German Society for Hygiene and Microbiology (DGHM). Given the recent recommendation of the German Standing Committee on Vaccination (STIKO) for conjugate meningococcal C vaccination of all children in the second year of life, observations from meningococcal C conjugate vaccination campaigns in other European countries were presented and compared to the German situation. Moreover, the newly implemented cluster detection routines employed at the NRZM and their integration into the interactive geographical information system EpiScanGIS were shown. Based on recent experiences from regional outbreaks in Oberallgäu, Sangerhausen, and Greater Aachen, examples for public health intervention were given at the conference. In addition, current developments in the area of meningococcal research, as well as trends in antimicrobial susceptibility were covered. Finally, the latest evidence concerning the clinical management and chemoprophylaxis of this invasive bacterial disease was discussed.

Functional and specific antibody responses in adult volunteers in new zealand who were given one of two different meningococcal serogroup B outer membrane vesicle vaccines.

This study presents detailed analyses of total and specific serum antibody levels among 26 and 24 adult volunteers before vaccination and after the third dose of the meningococcal serogroup B outer membrane vesicle (OMV) vaccines MeNZB and MenBvac, respectively, in a clinical trial in New Zealand (V. Thornton, D. Lennon, K. Rasanathan, J. O'Hallahan, P. Oster, J. Stewart, S. Tilman, I. Aaberge, B. Feiring, H. Nokleby, E. Rosenqvist, K. White, S. Reid, K. Mulholland, M. J. Wakefield, and D. Martin, Vaccine 24:1395-1400, 2006). With the homologous vaccine strains as targets, both vaccines induced significant increases in serum bactericidal and opsonophagocytic activities and in the levels of immunoglobulin G (IgG) to OMV antigens in an enzyme-linked immunosorbent assay (ELISA) and to live meningococci by flow cytometry. They also induced high levels of activity against the heterologous strains, particularly in terms of opsonophagocytic activity and IgG binding to live bacteria. The antibody levels with the homologous and heterologous strains in the four assays showed high and significant positive correlations. Specific IgG binding to 10 major OMV antigens in each vaccine was measured by scanning of immunoblots; ELISAs for two antigens, lipopolysaccharide and Neisseria surface protein A (NspA), were also performed. Both vaccines elicited significant increases in IgG binding to all homologous and heterologous OMV antigens except NspA. The total IgG band intensity on the blots correlated significantly with the IgG levels determined by the OMV ELISA and flow cytometry. In conclusion, the results of the various immunological assays showed that both OMV vaccines gave rise to high levels of specific and cross-reacting antibodies.