M. Pfisterer

The Effect of Age on Lower Urinary Tract Function: A Study in Women

OBJECTIVES: To identify age‐associated changes in female lower urinary tract function across a wide age spectrum, controlling for detrusor overactivity (DO).

Cognitive Impairment Decreases Postural Control During Dual Tasks in Geriatric Patients with a History of Severe Falls

Objectives: To investigate the influence of dual tasks, cognitive strategies, and fear of falling on postural control in geriatric patients with or without cognitive impairment and with a history of falls resulting in injury.

Two years later: a prospective long-term follow-up of a training intervention in geriatric patients with a history of severe falls.

OBJECTIVE To study the long-term outcome of a physical training regimen of ambulant postward rehabilitation in community-dwelling geriatric patients with a history of injurious falls. DESIGN Prospective 2-year follow-up of a randomized placebo-controlled intervention trial. SETTING Postward rehabilitation in a geriatric hospital in Germany. PARTICIPANTS Fifty-seven geriatric patients (mean age, 84.3+/-4.4 y) with a history of severe falls. INTERVENTION Ambulatory training of strength, functional performance, and balance 3 times a week for 3 months for 31 patients versus placebo activities for 26 patients. MAIN OUTCOME MEASURES Strength, functional performance, fall-related psychologic parameters, and physical activity assessed by standardized protocols 2 years after the training intervention, compared with baseline results. RESULTS Motor performance decreased substantially in both groups. As patients in the intervention group declined from significantly improved motor performance levels achieved in the initial training intervention, differences between the groups were still significant in most functional performances 2 years later. Functional decline was greater in persons who were institutionalized or being cared for by family members. Physical activity, which increased during the exercise intervention, returned to low baseline levels. CONCLUSIONS Improved functional performance in the training group did not lead to an increased level of physical activity after training, which might have preserved the functional improvements. In mobility-restricted, frail, geriatric patients such as our study population, training programs should continue to keep patients active and to prevent the decline in strength and functional performance that precedes loss of autonomy.

The Impact of Detrusor Overactivity on Bladder Function in Younger and Older Women

PURPOSE We examined the relationship of DO and aging, and bladder function in female volunteers. MATERIALS AND METHODS We recruited 85 cognitively competent, fully functional female volunteers who were 22 to 90 years old (median age 54) with and without symptoms suggestive of DO. Comprehensive assessment included a bladder diary, uroflowmetry and videourodynamics. We examined predefined urodynamic and diary variables for associations with DO and age, summarizing results in the 3 subgroups no DO, intermediate DO and clinically relevant DO. RESULTS Compared to women without DO those with DO showed a decrease in maximum cystometric capacity (558 vs 448 ml), mean daytime voided volume (260 vs 175 ml) and volume at strong desire to void (363 vs 283 ml) but an increase in maximum isovolumetric pressure (41 vs 64 cm H2O) and maximum detrusor pressure during involuntary contraction (intermediate and relevant DO 22 and 37 cm H2O, respectively). The positive association between increased detrusor contraction strength and DO was present at younger ages but absent in older subjects. Maximum urethral closure pressure and detrusor contraction strength decreased significantly with age. CONCLUSIONS From young adulthood to old age DO appears to affect bladder function parameters. It is associated with decreased bladder capacity and increased bladder sensation. Moreover, in younger adults DO is also associated with increased detrusor contraction strength, which is an association not seen in older individuals. This age associated loss of muscle function may be related to sarcopenia, implying that different treatments may be appropriate in older adults.

ROllATOR USe ADveRSely IMPACTS ON ASSeSSMeNT OF GAIT AND MObIlITy DURING GeRIATRIC ReHAbIlITATION

OBJECTIVE To investigate the influence of the use of a rollator walking aid on assessment of gait and mobility. DESIGN Prospective, longitudinal study. SUBJECTS Geriatric patients during inpatient rehabilitation (n=109; mean age 83.1 years). METHODS Assessment at the beginning and prior to discharge from rehabilitation using: gait-analysis (GAITRite®, speed, cadence, stride-time, stride-length, base-of-support, double-support), Performance-Oriented-Mobility-Assessment (POMA), and Timed-Up-and-Go (TUG). Differences between outcomes obtained without and with rollator use were calculated for baseline assessment and for changes over time for the total group and subgroups according to diagnosis (hip fracture vs. other). Responsiveness was calculated using standardized response means. RESULTS Baseline performances were significantly (p ≤ 0.05) higher when assessed with vs. without rollator in the total group and in hip fracture (except cadence) and other (except cadence, stride-time, TUG) patients. Changes over time were significantly greater when assessed without vs. with rollator in the total group and hip fracture (except cadence, POMA) and other patients (except base-of-support, double-support). Tests without rollator showed superior responsiveness (except TUG). CONCLUSION The use of rollator walking aids limits the detection of initial gait and mobility deficits, adversely affects the assessment of changes over time in gait and mobility performance, and reduces the responsiveness of tests. When full weight-bearing is permitted, assessment without a walking aid is recommended.

A common definition of geriatric palliative medicine.

To the Editor: Twenty percent of the European population is aged 60 and older (144 million), and 15% is aged 80 and older (108 million). By 2050, the proportion of the population aged 80 and older will reach 26% (187 million). In this scenario, the prevalence of disability, frailty, and comorbidity will grow quickly and will increasingly affect provision of health care by increasing costs for inpatient care and medications, the need for formal caregiving, and the prevalence of acute complications and adverse outcomes. Because physicians will be expected to provide optimal care for older persons, including those who are terminally ill, they will need to have some specific skills. Treating these patients’ complex social, psychological, and medical needs requires state-of-the-art geriatrics and palliative care knowledge and is best accomplished using a multidisciplinary, team-based approach. Palliative care for these patients involves not only treating the primary disease process and managing the patients’ multiple chronic medical conditions and geriatric syndromes, but also assessing and treating the physical and psychological symptom distress and establishing appropriate goals of care and treatment plans in the setting of unpredictable prognoses. Good palliative and geriatric medicine are closely related, although the aim of geriatric medicine is more often centered on the improvement, the rehabilitation, or the stabilization of a patient’s situation. Palliative medicine principles do not completely fit older patients because of the need for a comprehensive geriatric assessment, the recognition of the unique features of symptom (e.g., pain in people with dementia), and the focus on ageand diseasespecific drug prescribing, different from good practice in mainstream palliative care. Previous studies suggest that pain and other symptoms are underassessed and undertreated and are associated with a number of negative outcomes. In March 2007, a group of European geriatricians involved in geriatric palliative medicine (GPM) met for the first time to discuss GPM in Europe. This group became an officially recognized group of the European Union Geriatric Medical Society (EUGMS) and met for the fifth time in May 2009. The main goal of the group is to establish a European network of physicians to improve GPM. During two of their meetings, the group met to discuss a definition of GPM. The aim of developing this definition was to encourage geriatricians to integrate the main principles of palliative care (symptom management, talk about dying, advance directives, recognition of the terminal phase of the care process so that patients and family can come to rituals and good-byes) into daily geriatric practice. To construct the definition, the group relied on the World Health Organization (WHO) definition of palliative care, the WHO booklet ‘‘Better Palliative Care for Older People,’’ and the definitions of geriatric medicine from different geriatric organizations. The complete interest group and the EUGMS committee have reviewed the definition. GPM is the medical care and management of older patients with health-related problems and progressive, advanced disease for which the prognosis is limited and the focus of care is quality of life. Therefore GPM

Körperliches Training im Alter

For the prevention of diseases and especially functional deficits in old age, physical activity is a simple, practicable and successful method. With increasing age and frailty or in rehabilitation training, these activities have to be more and more individualized and medically supervised. The paper defines from todays viewpoint suitable activities and the amount of training necessary. Finally, the need for research about physical training in geriatric medicine is pointed out.ZusammenfassungZur Prävention von Krankheiten und insbesondere Funktionsstörungen im Alter ist die körperliche Aktivität einfach, praktikabel und erfolgreich einzusetzen. Je älter und gebrechlicher die Menschen und mehr rehabilitative Ziele angestrebt werden, desto individueller und medizinisch fundierter muss ein Training gestaltet werden. Die Arbeit gibt Hinweise, welche Aktivitäten nach derzeitigem Kenntnisstand geeignet sind und wie viel Aktivität notwendig ist. Nicht zuletzt wird der erhebliche Forschungsbedarf bei körperlichem Training in der Geriatrie benannt.SummaryFor the prevention of diseases and especially functional deficits in old age, physical activity is a simple, practicable and successful method. With increasing age and frailty or in rehabilitation training, these activities have to be more and more individualized and medically supervised. The paper defines from today’s viewpoint suitable activities and the amount of training necessary. Finally, the need for research about physical training in geriatric medicine is pointed out.

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 patients 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.

Palliative care for patients with dementia

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 patients 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.

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.ZusammenfassungWir untersuchten den Einfluss von repressiven Coping-Strategien, kognitiver Leistung, Depression, Bildung und Alter auf Patienten-Berichte zu definierten Variablen des Gesundheitsstatus bei 80 geriatrischen Patienten nach schwerem Sturz. Als Variablen der Patientenberichte wurden subjektive Angaben zur Vermeidung von körperlicher Aktivität, die subjektive Einschätzung, dass der Tode bevorsteht, Sturzangst, und Stürze erhoben. Die Co-Morbidität und Anzahl der Medikamente wurde aus den Patientenakten dokumentiert.Repressives Coping war signifikant assoziiert mit geringerer Bericht-Häufigkeit der Patienten in allen erhobenen Variablen und stellte einen signifikanten Prädiktor für fast alle Variablen aus Patientenberichten dar. Aufgrund der unzureichenden Aussagen zu Gesundheitsproblemen weisen geriatrische Patienten, die repressive Coping-Strategien benützen, möglicherweise ein höheres Risiko auf, medizinisch nicht adäquat behandelt zu werden.