A. Rösler

Adherence to Medication in Patients with Dementia : Predictors and Strategies for Improvement

Measures to facilitate patient medication adherence should be considered an integral part of the comprehensive care of older patients with multiple diseases. However, impairment of cognitive functions and dementia, in particular, may substantially compromise adherence behaviour. Therefore, a literature review was performed to identify factors associated with adherence to medication in patients with cognitive impairment or dementia, and to discuss strategies for improvement of non-adherence.Evidence-based information on how to deal with adherence to medication in patients with dementia is scarce because of a lack of specific studies. However, there is increasing knowledge about factors influencing medication adherence behaviour in older age, and emerging insight into the relationships between adherence behaviour and cognitive capacity, memory and executive function, in particular. Nevertheless, understanding elderly persons’ strategies for maintaining regular use of even complex drug regimens is still limited. Progress of research in this field is needed. It is notable that measures to improve adherence consist of combinations of educational interventions and cognitive support but assessment of study participants’ cognitive function is rare.In clinical practice, awareness of non-adherence as a result of cognitive impairment is relatively low. The most important step is early detection of cognitive impairment when this is impacting negatively on medication management. A practical geriatric screening test is recommended to identify memory problems and further functional impairments associated with cognitive impairment. Performance-based assessments might be useful for screening medication management capacity, in addition to a careful drug history, inspection of all medicines used (including over-the-counter drugs) and proxy information. However, no feasible screening methods have as yet found their way into clinical practice. Patients with impaired executive function, lack of awareness of illness and personality traits such as independency and high self-confidence may be at particular risk of non-adherence. The question is when to switch patient medication self-management to another person’s responsibility if cognitive decline progresses.Further research is needed on measures to differentiate cognitive function and the relationships between memory concerns, memory strategy use and medication management. Also, studies evaluating the influence of personal support, health status and depression on the memory strategies used are needed. It is important to assess patients’ attitudes toward medication and their relationship with proxies. Strategies for facilitating medication adherence in patients with dementia include prescribing as few medicines as possible, tailoring dose regimens to personal habits, and coordinating all drug dosing schedules as much as possible. When providing medication organizers, it is important to observe the patient’s ability to use devices appropriately. In addition, automated computer-based reminding aids, online medication monitoring and telemonitoring may be helpful for patients with mild dementia. The decision as to when assistance with medication self-management is needed has to be made taking into account patient independency and safety aspects. This holds true for medicines with a narrow therapeutic range, in particular. Interactions among the individual patient’s cognitive status, mood, level of self-efficacy and particular living situation must also be taken into consideration when searching for the optimal medication adherence strategy. No evidence-based recommendations can be given as yet. However, comprehensive assessment of the individual patient and careful consideration of all potential drug-related problems will probably help facilitate adherence and prevent compromised health outcomes in patients with dementia.

Medizin des Alterns und des alten Menschen

ZusammenfassungInhalte der Altersmedizin wurden bislang im Medizinstudium in Deutschland nur vereinzelt und fakultativ an Universitäten und Medizinischen Hochschulen angeboten. Die reformierte Approbationsordnung enthält als einen neuen Querschnittsbereich die „Medizin des Alterns und des alten Menschen“ obligatorisch im klinischen Studienabschnitt. Verbindliche Lerninhalte liegen für diesen Querschnittsbereich jedoch nicht vor. Dieser Bericht beschreibt deshalb ein neu entwickeltes Curriculum mit seinem Schwerpunkt auf Seminaren in kleinen Gruppen, die ersten Erfahrungen sowie die Ergebnisse der Evaluation des Unterrichts durch Studierende an der Universität Hamburg. Die Ergebnisse belegen eine hohe Akzeptanz von Inhalt und Form des Unterrichts, der von den befragten Studierenden als interessant und lehrreich eingeschätzt wurde.SummaryUntil 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 didactical teaching were both well accepted by the students and judged as interesting and instructive.

Nutritional and hydration status in elderly subjects: Clinical rating versus bioimpedance analysis

Malnutrition and dehydration are common in elderly. A simple, reliable instrument to assess nutritional and hydration status would be very helpful. Bioelectrical impedance analysis (BIA) has been promising in this context, but data of elderly persons and geriatric in-hospital patients are rare. Therefore, we first compared BIA measurements (resistance, reactance, phase angle and a resulting vectorgraph) with a clinical assessment in 31 community-dwelling women and 30 female nursing-home residents. The results of the BIA measurement correlated well to weight, hand grip strength, and calf circumference. We then compared BIA measurements with clinical judgement of hydration status in 103 acute geriatric hospital in-patients. Concordance between the results of clinical judgement and BIA measurements was only 43.7%. In assessing geriatric in-patients, there is little concordance between the clinical and the bioelectrical evaluation of the hydration status.

Spezialisierte Stationen zur Behandlung von akut erkrankten geriatrischen Patienten mit zusätzlichen kognitiven Beeinträchtigungen in Deutschland

ZusammenfassungIn den letzten Jahren sind im Rahmen akutgeriatrischer Versorgung vermehrt Stationen eröffnet worden, die sich auf die Behandlung körperlich erkrankter und zusätzlich kognitiv eingeschränkter Patienten spezialisiert haben. Bisher gibt es kein allgemein gültiges Konzept bzw. keine Mindestanforderungen an eine solche Station. Eine Umfrage unter zwölf solchen, zumeist offen geführten Stationen verdeutlichte ihre charakteristischen Merkmale: Erweiterung des geriatrischen Assessments, Weiterbildungen der Mitarbeiter, insbesondere in den Bereichen Validation und Gerontopsychiatrie, sowie Besonderheiten der Ausstattung mit getarnten Ausgängen, Gemeinschaftsräumen und zum Teil Rundläufen und Therapieräumen auf Station. Große Unterschiede waren bei den Bezeichnungen der Stationen, den Bettenzahlen, den Verweildauern und den Auswahlkriterien für Patienten festzustellen. Ein Erfahrungsaustausch zwischen den so arbeitenden Stationen und eine gemeinsame Forschung hinsichtlich des Nutzens der Konzepte erscheinen notwendig.AbstractDuring 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.

Dementia as a cofactor for geriatric rehabilitation-outcome in patients with osteosynthesis of the proximal femur: A retrospective, matched-pair analysis of 250 patients

A raising number of patients with osteosynthesis of the proximal femur and additional dementia will be seen in hospitals in the future due to demographic changes. There is an ongoing discussion, if and to what extent cognitive abilities do influence functional outcome in geriatric rehabilitation. We therefore compared 250 patients with osteosynthesis of the proximal femur of whom one half had additional dementia, by a matched-pair analysis for the improvement of mobility assessed by the mobility items of the Barthel Index and the Tinetti mobility index. Dementia was an important cofactor for the success of geriatric rehabilitation. Patients with additional dementia reached lower mobility scores at discharge. Also, patients with dementia had significantly more in-hospital falls. Furthermore, the study revealed that demented patients received less individual and group therapy per hospital day. The study underlines the need for specialized wards treating demented patients with additional illnesses.

Dysphagia in Dementia: Influence of Dementia Severity and Food Texture on the Prevalence of Aspiration and Latency to Swallow in Hospitalized Geriatric Patients

OBJECTIVES To evaluate influences of disease severity and food texture on prevalence and type of dysphagia in hospitalized geriatric patients. DESIGN We screened for dysphagia in 161 geriatric inpatients with different forms of dementia and 30 control patients. MEASUREMENTS Signs of aspiration were registered with 3 different food consistencies (water, apple puree, and slice of an apple) and the latency until the first swallow was documented. SETTING Geriatric department of an academic teaching hospital in Hamburg, Germany. RESULTS Compared with the controls, patients with dementia more often showed signs of aspiration. In the patients with dementia, signs of aspiration occurred more frequently with water (35.6%) than with a slice of an apple (15.1%) or apple puree (6.3%). We observed an inverse relationship between Mini-Mental State Examination score level and the suspected rate of aspiration, as well as with the length of latency until the first swallow of puree. CONCLUSIONS The prevalence of dysphagia is high in patients with dementia, especially in patients with moderate to severe cognitive impairment. The relationships observed in this study encourage screening for dysphagia and adapting meal consistencies to prevent aspiration in patients with dementia.

Visual Search in Patients with Subcortical Vascular Dementia: Short Fixations but Long Reaction Times

Visual search is a cognitive function of high ecological relevance. It involves rapid alternations between allocating and shifting attention. In patients with Alzheimer’s disease, the duration of fixations during visual search increases already in the early stage of the illness. Subcortical vascular dementia (SVD), a newly defined subgroup of vascular dementia, has not yet been examined in this respect. SVD affects patients with a history of lacunar infarctions and/or transient ischemic attacks, focal neurological signs and evidence of subcortical white matter lesions as well as lacunes in the deep grey matter. Here, we report our findings from tracking eye movements during a visual search task with different array sizes in 9 patients with SVD and compare the number and duration of eye fixations they made with the values obtained in 9 healthy elderly control subjects. While patients with SVD were significantly slower in the tasks with longer center to target distances (mean reaction time), the number and duration of fixations they made did not differ from those in controls. Impairment of visual search in patients with SVD seems to be an effect of general cognitive slowing in more demanding arrays of visual search rather than a specific deficit in parameters of eye fixation.

Was die Sprache Alzheimer-Kranker mit der Celans verbindet

ZusammenfassungDer Kontakt mit schwer betroffenen Demenzkranken verlangt eine grundlegende Umgestaltung der Kommunikationsweise. Dabei hilfreich ist eine Umorientierung von einer interpretierenden, häufig defizitorientierten Sichtweise, hin zu einer besonderen Aufmerksamkeit gegenüber ungewöhnlichen verbalen und nonverbalen Äußerungen sowie Ressourcen der Erkrankten. Die Hinwendung von einem ergebnisorientierten Informationsaustausch mit dem Patienten hin zu spontaner und offener Kommunikation stellt für alle Gesundheits- und Sozialberufe eine anspruchsvolle Herausforderung dar.Das Wohlergehen von Personen mit Demenz wird maßgeblich durch die Qualität der Kommunikation und der Gestaltung der Umgebung und des Tagesablaufs beeinflusst. Notwendig für eine erfolgreiche Pflege ist die professionelle Gestaltung der pflegerischen Interaktion, die Spontaneität und Kreativität von Seiten beider Pflegepartner Raum gibt und die in der charakteristischen Personen-, Alltags- und Körpernähe der Pflege von Menschen mit Demenz die persönlichen Grenzen beider wahrt. Der Aufsatz behandelt Aspekte und Regeln der adäquaten Kommunikationsgestaltung mit Menschen mit Demenz aus der Sicht der Medizin und der Pflege. Wege zur Verbesserung der Kommunikation werden u. a. anhand der Ansätze von Kate Allan und John Killick (Research Fellows des Dementia Services Development Centre, University of Stirling) aufgezeigt.SummaryBeing 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).

SENTENCES WRITTEN DURING THE MINI‐MENTAL STATE EXAMINATION: CONTENT AND DIAGNOSTIC VALUE IN COGNITIVELY HEALTHY ELDERLY PEOPLE AND PATIENTS WITH DEMENTIA

Financial Disclosure: None of the authors had any financial conflicts. Author Contributions: Tatsuya Suzuki contributed toward study concept and design, acquisition of subjects and/ or data, analysis and interpretation of the data, and preparation of manuscript. Shoko Futami, Yoshimasa Igari, Noriaki Matsumura, Kentaro Watanabe, Hiroshi Nakano, Kenzo Oba, Yuichi Murata, Hitoshi Koibuchi, and Yoshiaki Kigawa all equally contributed to the acquisition of subjects, data, or both and to analysis and interpretation of the data. Sponsor’s Role: None.

Effects of Subcortical Vascular Ischemic Dementia and Aging on Negative and Neutral Word List Learning

Background: Subcortical ischemic vascular dementia (SIVD) represents an important subgroup of vascular dementia. Besides characteristic cognitive deficits, particular emotional problems support the diagnosis. Emotional disturbances in SIVD are not well understood. Method: We studied the performance of SIVD patients, healthy young control persons and old control persons in an emotional word list learning task. Results: SIVD patients showed lower memory performance than both control groups for neutral as well as for negative words. However, we found a significant emotional memory advantage for negative words in all 3 diagnostic groups. Conclusion: SIVD patients are able to profit from emotional information in order to enhance their memory performance.