Supporting dementia patients in hospital environments: health-related risks, needs and dedicated structures for patient care.

The diagnostics and treatment of dementia are progressively gaining importance for European neurologists. Our hospital structures are poorly prepared for patients suffering from dementia. As a consequence of cognitive and physical deficits, dementia patients have an increased risk for serious complications and poor outcomes in hospital environments. In this review, the specific needs of dementia patients are outlined, describing how geriatricians, neurologists and psychiatrists may contribute to better patient care, e.g. with consultation or liaison services, geriatric wards, dedicated dementia wards or memory clinics in interaction with nurses, occupational therapists, physiotherapists, speech therapists, psychologists and social workers. Due to their multifaceted needs, dementia patients can most successfully be supported in clinical environments that closely integrate specialized inpatient, outpatient and primary care offers.

Supporting dementia patients and their caregivers in daily life challenges: review of physical, cognitive and psychosocial intervention studies.

BACKGROUND AND PURPOSE: Dementia is associated with multiple daily life challenges that have a major impact for health outcome, affecting both the patients and their caregivers. In this review, the efficacy of physical, cognitive and psychosocial interventions in the treatment of dementia patients is evaluated, and how caregiver education and support may contribute to patient care is analysed. RESULTS AND CONCLUSIONS: Due to the complex nature of cognitive and psychosocial interventions, their efficacy depends strongly on local settings. Thus, active components of these interventions are not always obvious, even in controlled randomized trials. Successful patient management includes (i) the safekeeping of basic support, (ii) the provision of a stable external milieu that is adjusted to the patients' cognitive resources and (iii) the provision of multimodal therapeutic concepts that are closely adapted to the practical needs of the patients and caregivers.

[Special care units for acutely ill patients with cognitive impairment in Germany. Position paper]. / Spezialstation für akut erkrankte, kognitiv eingeschränkte Patienten in Deutschland. Positionspapier.

BACKGROUND: Dementia is an increasing challenge for care providers in nursing homes and hospitals. Since the 1980s, special acute care units in nursing homes have developed rapidly. In Germany, the first unit in a hospital opened in 1990. In 2013, there were 22 units. MATERIALS AND METHODS: In the following paper, the German Geriatric Society ("Deutsche Gesellschaft für Geriatrie e. V.") recommends basic standards for these wards. RESULTS: The basic standards for these wards include the following: a maximum of 20 beds, an area physically separated from the geriatric hospital department, their own dayroom and therapy room, a structured daily routine suitable for patients with dementia, the selection of permanent staff on a voluntary basis, specialized training, extended geriatric assessment, and special consideration of the background and social situation of the patients.

The terminal phase of life as a team-based clinical global judgment: prevalence and associations in an acute geriatric unit.

BACKGROUND: In most elderly people, the final-terminal-phase of life is characterized by permanent dependency and a complete inability to perform activities of daily living. Treatment targets usually switch from rehabilitation to palliation. However, the prevalence of the clinical judgment "last phase of life" and its association with in-hospital death is unknown in geriatric patients. PATIENTS AND METHODS: We retrospectively analyzed GEMIDAS data from two geriatric units. Patients without cancer and an in-hospital stay of at least 1 week were included in our study. Prevalence of the terminal phase of life was clinically assessed according to the proposals made by M. Gillick. This clinical judgment was pronounced by the geriatric team after a stay in the hospital of at least 1 week. The clinical judgment took into account all available assessment parameters, as well as the impact of a geriatric treatment trial. In addition, the association between the clinical judgment and the risk of in-hospital mortality was analyzed. RESULTS: Records from 2,433 (56%) patients in hospital A and from 1,912 (44%) patients in hospital B were analyzed. The frequency of a terminal phase of life was 30% and 9% (p<0.01), respectively. The frequency depended on the manner of admission to the hospital. In both hospitals, mortality was significantly higher in terminal patients (27% and 37%) than in other patients (0-8% and 0-6%). In both hospitals, the risk of in-hospital mortality was significantly associated with the clinical judgment (OR 3.1 and 2.7), heart failure (OR 2.2 and 2.1), and dementia (OR 2.0 and 1.8). Age, residency in a nursing home, and the Barthel Index on admission were all without relevant impact. CONCLUSION: The frequency of the clinical construct "terminal phase of life" varies in geriatric units between 9% and 30%. This clinical construct is significantly associated with increased in-hospital mortality. Therefore, this construct possesses external validity. Further studies are needed in order to assess the significance of such a clinical judgment, the associations with clinical burdens of symptoms, and the supply structure required to cover the needs of patients and their families.

[Special care units for the treatment of acutely ill, cognitively impaired geriatric patients in Germany]. / Spezialisierte Stationen zur Behandlung von akut erkrankten geriatrischen Patienten mit zusätzlichen kognitiven Beeinträchtigungen in Deutschland.

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.

[Importance of molecular diagnostics in Alzheimer dementia. A case report]. / Stellenwert der molekularen Diagnostik bei Alzheimer-Demenz. Ein Fallbeispiel.

Alzheimer's disease (AD) is the most frequent form of dementia worldwide. The increasing incidence of AD is due to the dramatic rise in life expectancy. Generally, AD shows a multifactorial etiology and manifests itself only at an older age. However, a small percentage of cases have a monogenic cause, are inherited as an autosomal dominant trait, and begin much earlier. In these cases, molecular analysis and genetic consultation may make sense.

[Significance of CSF levels of tau protein and beta42-amyloid for diagnosis and differential diagnosis of dementia diseases in a specialized geriatric hospital]. / Stellenwert der Liquordiagnostik für die Diagnose und Differenzialdiagnose demenzieller Erkrankungen in einer geriatrischen Fachklinik.

Considering the incidence of dementia, the development of procedures that allow correct differential diagnosis is gaining increasing importance. The analysis of spinal fluid from 632 patients, who were admitted with suspected dementia, diagnosed dementia or dementia of unclear etiology, showed that there was high differential diagnostic power for tau protein, but not for beta-amyloid.

[Changes of a sample of aged > or = 60 years of age in-patients after five years: results from the ELDERMEN-Study]. / Veränderung einer Stichprobe > or = 60-jähriger Krankenhauspatienten nach 5 Jahren: Ergebnisse der ELDERMEN-Study.

METHOD: The ELDERMEN Study, which was funded by the German Research Association, comprises baseline assessment during 1994-1997 and a second assessment during 2000-2002. A total of 261 in-patients participated in an extensive examination at baseline assessment and were contacted again five years later. RESULTS: Five years after baseline assessment, 135 former participants had deceased, 29 newly fulfilled exclusion criteria. Of the 97 individuals who matched the study's inclusion criteria at the second assessment, 74 participated in the second evaluation. Baseline assessment revealed no significant differences between participants at second assessment and those persons who refused the second participation. However, participants in the extensive examination and longitudinal design were a positive selection when compared to the whole baseline sample. DISCUSSION: Because of increasing morbidity and mortality, longitudinal gerontological studies have to deal with the problem of selective diminishment of the sample, which can endanger the validity and generalizability of results. The problem has to be dealt with by careful documentation and evaluation of selectivity effects. We focus on the problems of longitudinal studies in gerontologic research and examine the longitudinal development of a sample of geriatric in-patients aged > or = 60 years.

The prevalence and differential diagnosis of subclinical depressive syndromes in inpatients 60 years and older.

BACKGROUND: Depressive syndromes that do not comply with the diagnostic criteria for specific depressive disorders are designated as 'subclinical' or 'subsyndromal' depressive syndromes. Using our own data from a clinical study, this paper outlines the significance of subclinical depressive syndromes and demonstrates the problems of differentiating between depressive and subclinical depression (SD) syndromes and organic mood disorders especially in an elderly population with medical comorbidity. METHODS: Two hundred and sixty-two patients aged 60 years and older in a general hospital were investigated, using a clinical psychiatric interview, expert ratings and self-report scales after extensive internal medical diagnostic evaluation. RESULTS: When, without further differentiation as to their origin, all symptoms required by symptom checklists according to ICD-10 were considered for the diagnosis of major depression (MD), 35.5% of the study participants fulfilled the diagnostic criteria. After differentiating for etiology of symptoms, MD was found in only 14.1%, SD was diagnosed in 17.6% and organic mood disorder in 12.2% of the study participants. In another 41 patients (15.6%), symptoms of depression not fulfilling ICD-10 criteria were classified as being of organic or drug-induced origin. SD patients were in a mean position between nondepressive and depressive patients with regard to social isolation and physical impairment; women were overrepresented in the depressive and subdepressive groups. CONCLUSIONS: SD and organic mood disorder are common and helpful diagnostic categories in the elderly. The results show that in old age there is substantial danger of confounding MD, SD and organic mood disorder, thus leading to erroneously high prevalence rates of MD and underestimations of organic mood disorder if depressive symptoms are recorded only by self-report scales or a symptom checklist. Both internal and psychosomatic-psychotherapeutic competence as well as a liaison service in general hospitals are necessary for the differential diagnosis of MD, SD and organic mood disorder in the elderly with medical comorbidity.

[The degree of Objective Health Burden (OHB) - an expert assessment of the impairment caused by somatic illnesses in geriatric medicine]. / Der grad Objektiver Gesundheitlicher Belastung (OGB) - ein Expertenrating zur diagnoseübergreifenden Schweregradeinschätzung Somatischer Erkrankungen in der Geriatrie.

The degree of Objective Health Burden (OHB) is an expert assessment of the impairment caused by somatic illnesses. It allows an overall clinical rating of the severity of a patient's somatic condition, considering all available information, not only the content or number of diagnoses. The rating on a five point scale is demonstrated with clinical examples. Interrater-reliability is satisfactory, being at least 0.74. External criteria indicate the OHB's validity. As the OHB is easy to comprehend and to employ, it is suitable for broad clinical application in geriatric basic assessment as well as for scientific purposes.

[Psychogenic impairment and current feelings in the elderly. Which options are offered by the biographical perspective?]. / Psychogene Beeinträchtigung und aktuelle Befindlichkeit im Alter. Welche Chancen eröffnet die biographische Perspektive?

In the Eldermen study funded by the German Research Association (DFG), a consecutive sample of patients, aged > or = 60 (n = 120) and being treated for a variety of internal medical complaints in an acute geriatric hospital were examined with the help of comprehensive somatic diagnostics, standardised questionnaires, and a semi-structured biographical interview. The study investigates the relationship between burdensome and supportive biographical experiences and the extent of psychogenic impairment as well as aspects of feeling tone and self-concept in later life. For the degree of psychogenic impairment (Impairment Score. IS; Schepank 1995), subjectively experienced burdens and support were found to be more relevant than "objective" burdens. As expected, subjective burdens consistently experienced over several life phases, particularly in association with limited experienced support, were found to be associated with greater psychogenic impairment and a higher "case risk" in later life. However, the patients with the highest values for current life satisfaction as well as a more positive self-concept were not those patients who never experienced more burdens than support in their biographies, but rather those who experienced more burden than support in one life phase. The results are presented in relation to models of learning theory and object relation theory and discussed for their clinical relevance.

[Patient assessment in suspected dementia]. / Abklärung bei Verdacht auf Demenzerkrankungen.

In the near future the number of patients suffering from cognitive impairment and senile dementia will increase because of the change in the structure of population. General practitioners and specialists will be confronted with this problem. The early and differential diagnosis of senile dementia is still a problem. Corresponding with the diagnostic algorithms of ICD 10 and DSM IV the diagnostic procedure is discussed with geriatric, neuro/psychiatric, psychological and psychosocial aspects. The diagnosis also relies on history obtained from family and friends. Although cognitive loss is considered a core symptom of senile dementia, loss of behavioral disinhibition, loss of functional autonomy and mood problems are considered as more important by clinicians and family and are of great diagnostic value. Psychometric tests are important but they are only one out of many different possibilities to find the right diagnosis. If it is possible different specialists should examine the patient. Out of the different methods and views of the specialists a comprehensive image of the patient takes shape and allows a better understanding of dementia.

[Early and differential diagnosis of 1,000 patients examined in a memory clinic]. / Früh- und Differentialdiagnose von 1000 in einer Memory-Clinic untersuchten Patienten.

The results from 1000 patients included in a consecutive sample of older persons showing signs of "age-related memory deficits" clearly demonstrate the necessity for a wide spectrum of differential diagnostic competence. The patients included in the study were diagnosed in succession by an interdisciplinary team of psychiatrists, neurologists, geriatric medical specialists, psychologists and gerontologists. The diagnostic process for clarification of DSM-III-R and ICD-10 criteria are discussed in detail. In all, 49.6% of the patients were diagnosed as suffering from dementia of the Alzheimer type, 31% from vascular dementia and 10% from a mixed form. In all, 12.5% of the patients were somatically ill and 31.4% displayed other psychiatric conditions, 50% of which were evaluated as being treatable with psychotherapy. The results are primarily discussed for their relevance to the reality of current treatment.

[Pain and pain perception in the elderly from the viewpoint of rheumatology]. / Schmerz und Schmerzerleben im Alter aus Sicht der Rheumatologie.

In rheumatology there is the problem of different terminologies and classification systems; additionally there are only few studies on differential diagnosis and course of diseases in people over 65. The analysis of pain is important for diagnosis; people often have problems in exactly describing their pains. The character of pain changes in the course of disease; therefore a continuous pain analysis is necessary.

[The geriatric team in the memory clinic]. / Das geriatrische Team in der Memory-Clinic.

The early and differential diagnosis of senile dementia is still a problem. The work of a multiprofessional team in the Memory Clinic Essen is reviewed. the combination of qualifications of the team corresponds with the diagnostic algorithms of DMS-III R and ICD 10. Members of the team are a geriatrician, a psychiatrist, a geragoque, and a psychologist. Every specialist examines the patient using his specialized method. The results are discussed in a diagnostic conference. Out of the different methods and views of the specialists a comprehensive image of the patient takes shape and allows a better understanding of the dementia.