Rahel Eckardt

Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version.

In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the “Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care”. Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidence used to formulate these recommendations was reviewed and approved by representatives of 17 national societies. Three grades of recommendation were used as follows: Grade “A” (strong recommendation), Grade “B” (recommendation) and Grade “0” (open recommendation). The result is a comprehensive, interdisciplinary, evidence and consensus-based set of level 3 guidelines. This publication was designed for all ICU professionals, and takes into account all critically ill patient populations. It represents a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine.

Efficacy of a vibrotactile neurofeedback training in stance and gait conditions for the treatment of balance deficits: a double-blind, placebo-controlled multicenter study.

Objective Vestibular rehabilitation strategies mostly require a long-lasting training in stance conditions, which is finally not always successful. The individualized training in everyday-life conditions with an intuitive tactile neurofeedback stimulus seems to be a more promising approach. Hence, the present study was aimed at investigating the efficacy of a new vibrotactile neurofeedback system for vestibular rehabilitation. Study Design Double-blinded trial. Patients One hundred five patients who experience one of the following balance disorders for more than 12 months were included in the study: canal paresis, otolith disorder, removal of an acoustic neuroma, microvascular compression syndrome, Parkinson’s disease, and presbyvertigo. Interventions Vibrotactile neurofeedback training was performed daily (15 min) over 2 weeks with the Vertiguard system in those 6 tasks of the Standard Balance Deficit Test with the most prominent deviations from the normative values. Main Outcome Measures Trunk and ankle sway, dizziness handicap inventory, and vestibular symptom score were measured in the verum and placebo group before the training, on the last training day and 3 months later. Results A significant reduction in trunk and ankle sway as well as in the subjective symptom scores were observed in the verum group. Such an effect could not be found in any of the outcome parameters of the placebo group. Conclusion The vibrotactile neurofeedback training applied in the present study is a highly efficient method for the reduction of body sway in different balance disorders. Because the rehabilitation program is easy to perform, not exhausting, and time saving, elderly patients and those with serious, long-lasting balance problems also can participate successfully.

The Bioimpedance Phase Angle Predicts Low Muscle Strength, Impaired Quality of Life, and Increased Mortality in Old Patients With Cancer

OBJECTIVES We investigated the impact of low phase angle (PhA) values on muscle strength, quality of life, symptom severity, and 1-year mortality in older cancer patients. DESIGN Prospective study with 1-year follow-up. PARTICIPANTS Cancer patients aged >60 years. METHODS PhA was derived from whole body impedance analysis. The fifth percentile of age-, sex-, and body mass index-stratified reference values were used as cut-off. Quality of life was determined with the European Organization of Research and Treatment in Cancer questionnaire, reflecting both several function scales and symptom severity. Muscle strength was assessed by hand grip strength, knee extension strength, and peak expiratory flow. RESULTS 433 cancer patients, aged 60-95 years, were recruited. Patients with low PhA (n = 197) exhibited decreased muscle strength compared with patients with normal PhA (hand grip strength: 22 ± 8.6 vs 28.9 ± 8.9 kg, knee extension strength: 20.8 ± 11.8 vs 28.1 ± 14.9 kg, and peak expiratory flow: 301.1 ± 118 vs 401.7 ± 142.6 L/min, P < .001). Physical function, global health status, and role function from the European Organization of Research and Treatment in Cancer questionnaire were reduced, and most symptoms (fatigue, anorexia, pain, and dyspnea) increased in patients with low PhA (P < .001). In a risk-factor adjusted regression analysis, PhA emerged as independent predictor of physical function (ß:-0.538, P = .023), hand grip strength (ß:-4.684, P < .0001), knee extension strength (ß:-4.548, P = .035), and peak expiratory flow (ß:-66.836, P < .0001). Low PhA moreover predicted 1-year mortality in the Cox proportional hazards regression model, whereas grip strength was no longer significant. CONCLUSIONS PhA below the fifth reference percentile is highly predictive of decreased muscle strength, impaired quality of life, and increased mortality in old patients with cancer and should be evaluated in routine assessment.

Association of Low Lean Mass With Frailty and Physical Performance: A Comparison Between Two Operational Definitions of Sarcopenia—Data From the Berlin Aging Study II (BASE-II)

BACKGROUND For prevention and treatment of sarcopenia, defined as a decline in lean mass, reliable diagnostic criteria and cutpoints reflecting a clinically relevant threshold are indispensable. As of yet, various parameters have been proposed but no gold standard exists. The aim of this study was to compare cutpoints of appendicular lean mass related to body mass index (ALMBMI) or height (ALM/height(2)) regarding their association with self-reported physical limitations and frailty status in a sample of community-dwelling older adults. METHODS A total of 1,343 participants from the Berlin Aging Study II were included. ALM index was assessed with dual-energy X-ray absorptiometry. Limitations in physical performance were assessed via questionnaire and frailty status was defined according to the Fried criteria. RESULTS In a risk factor-adjusted analysis, participants with an ALMBMI below the cutpoints had 1.4-2.8 times higher odds of difficulties in several domains of physical activity (p = .031 to p < .0001) compared with participants with normal ALMBMI. In participants with low ALM/height(2), no associations with physical limitations were found. Moreover, the odds of being prefrail/frail were statistically significant for the low ALMBMI group only (odds ratio = 2.403, 95% confidence interval: 1.671-3.454, p < .0001) and not for the low ALM/height(2) group. CONCLUSIONS This study showed striking differences between the two operational criteria ALM/height(2) and ALMBMI concerning their association with physical limitations and prefrailty/frailty. The low ALMBMI cutpoints seem suitable to detect patients at risk for negative outcomes such as frailty who might benefit from interventions targeted at improving lean mass.

Single lipoprotein apheresis session improves cardiac microvascular function in patients with elevated lipoprotein(a): detection by stress/rest perfusion magnetic resonance imaging.

The aim of this study was to explore the effects of a single lipoprotein apheresis session on myocardial stress/rest (S/R) perfusion in patients with elevated lipoprotein(a) (Lp(a)) and coronary artery disease using cardiac magnetic resonance imaging. Twenty patients with Lp(a) > 60 mg/dL and coronary artery disease were randomized into a control or a treatment group. Both groups underwent cardiac magnetic resonance imaging with assessment of left ventricular function, perfusion and viability, and the treatment group underwent lipoprotein apheresis immediately afterwards. Repeat magnetic resonance imaging was performed at 24 h for both groups and at 96 h for just the treatment group. The transmyocardial perfusion gradient (i.e. endo‐epi ratio [EER]) was determined and a comprehensive parameter of resting and adenosine‐induced stress perfusion was derived (EER‐S/R). While the hematocrit remained unchanged, apheresis reduced lipoproteins and rheological parameters: Lp(a) − 55.1%, total cholesterol − 34.5%, low density lipoprotein (LDL) − 54.6%, Lp(a)‐corrected LDL − 54.3%, high density lipoprotein − 17.4%, apolipoprotein B − 39.2%, plasma viscosity − 10.7%, and fibrinogen − 30.6% at 24 h (P < 0.05 for all). At 96 h these parameters, except for plasma viscosity, apolipoprotein B and Lp(a)‐corrected LDL, recovered but did not reach baseline values (P < 0.05 for all). The EER‐S/R at 24 h was lowered by therapy (ΔEER‐S/R 5%; P < 0.03), whereas this effect disappeared at 96 h. The ejection fraction (EF) was slightly improved at 24 h (67.07 ± 6.28% vs. 64.89 ± 6.39%; ΔEF 2.2%, P < 0.05) and returned to baseline at 96 h. In the control group no corresponding changes were detected. In conclusion, cardiac magnetic resonance imaging detects subtle treatment‐related changes in regional myocardial perfusion in patients with elevated Lp(a) and coronary artery disease undergoing lipoprotein apheresis.

Evaluation of central auditory discrimination abilities in older adults

The present study focuses on auditory discrimination abilities in older adults aged 65–89 years. We applied the “Leipzig inventory for patient psychoacoustic” (LIPP), a psychoacoustic test battery specifically designed to identify deficits in central auditory processing. These tests quantify the just noticeable differences (JND) for the three basic acoustic parameters (i.e., frequency, intensity, and signal duration). Three different test modes [monaural, dichotic signal/noise (s/n) and interaural] were used, stimulus level was 35 dB sensation level. The tests are designed as three-alternative forced-choice procedure with a maximum-likelihood procedure estimating p = 0.5 correct response value. These procedures have proven to be highly efficient and provide a reliable outcome. The measurements yielded significant age-dependent deteriorations in the ability to discriminate single acoustic features pointing to progressive impairments in central auditory processing. The degree of deterioration was correlated to the different acoustic features and to the test modes. Most prominent, interaural frequency and signal duration discrimination at low test frequencies was elevated which indicates a deterioration of time- and phase-dependent processing at brain stem and cortical levels. LIPP proves to be an effective tool to identify basic pathophysiological mechanisms and the source of a specific impairment in auditory processing of the elderly.

Prevalence and definition of sarcopenia in community dwelling older people: Data from the Berlin Aging Study II (BASE-II)

BackgroundSarcopenia describes the age-associated loss of muscle mass, strength and function. The aim of this study was to compare the prevalence of sarcopenia in a cohort of community dwelling elderly people living in Berlin, Germany, according to the criteria proposed by current consensus statements and to study the respective impact on self-reported physical performance.Material and methodsThis study included 1405 participants from the Berlin aging study II (BASE-II). The appendicular skeletal muscle mass index (SMI) was assessed with dual energy X-ray absorptiometry (DXA), muscle strength was measured by hand grip strength and the timed up and go” test (TUG) was performed as a functional parameter to reflect mobility.ResultsThe prevalence of sarcopenia was 24.3 % in terms of reduced SMI only and considerably lower for sarcopenia with reduced grip strength (4.1 %) and sarcopenia with limited mobility (2.4 %). Only 0.6 % of the participants fulfilled all three criteria. Of the subjects with a normal SMI, 8.6 % had reduced grip strength and 5.1 % had limited mobility, whereas 1.3 % subjects fulfilled both criteria. Participants with reduced strength or function reported severe difficulties in performing physical tasks significantly more often than participants with normal or reduced SMI alone (p <0.029–p <0.0001).ConclusionIn BASE-II low skeletal muscle mass was much more frequent than reduced grip strength or poor function. Reduced strength and function were found to be associated with a greater impact on physical performance than reduced muscle mass. Low SMI does not seem to be a prerequisite for low strength or limitations in mobility.ZusammenfassungHintergrundSarkopenie beschreibt den altersassoziierten Verlust von Muskelmasse, -kraft und -funktion. Ziel dieser Studie war es, die Sarkopenieprävalenz in einer Stichprobe zu Hause lebender Senioren nach verschiedenen, gegenwärtig empfohlenen Kriterien zu bestimmen und einen Zusammenhang mit subjektiver physischer Leistungsfähigkeit in Aktivitäten des täglichen Lebens zu erforschen.Material und MethodeUntersucht wurden 1405 Teilnehmer der Berliner Altersstudie II (BASE-II). Appendikuläre Skelettmuskelmasse und Skelettmuskelmasseindex (SMI) wurden mittels Doppel-Röntgen-Absorptiometrie (DXA) bestimmt. Die Muskelkraft wurde als Greifkraft gemessen, und die Mobilität als funktioneller Parameter mit dem Timed-up-and-go-Test (TUG) eingeschätzt.ErgebnisseDie Prävalenz der Sarkopenie betrug 24,3 % bezogen auf einen niedrigen SMI als alleiniges Kriterium und zeigte sich erheblich niedriger in Kombination der Kriterien niedriger SMI und reduzierte Greifkraft (4,1 %) oder niedriger SMI und eingeschränkte Mobilität (2,4 %). Nur 0,6 % aller Teilnehmer erfüllten alle 3 Kriterien. Von Teilnehmern mit normalem SMI hatten 8,6 % eine reduzierte Greifkraft und 5,1 % eine eingeschränkte Mobilität. Im Vergleich zu Teilnehmern mit normaler Kraft oder Funktion gaben jene mit reduzierter Kraft oder Funktion signifikant häufiger Schwierigkeiten in der physischen Performance an (p <0,029–p <0,0001).DiskussionEine reduzierte Skelettmuskelmasse zeigte sich erheblich häufiger als eine reduzierte Greifkraft oder eingeschränkte Mobilität. Ein niedriger SMI scheint keine Voraussetzung zu sein für eine verringerte Muskelkraft oder -funktion, die ihrerseits einen stärkeren Zusammenhang mit der subjektiven physischen Leistungsfähigkeit von Senioren aufwiesen als eine reduzierte Muskelmasse.

Prevalence and definition of sarcopenia in community dwelling older people

BackgroundSarcopenia describes the age-associated loss of muscle mass, strength and function. The aim of this study was to compare the prevalence of sarcopenia in a cohort of community dwelling elderly people living in Berlin, Germany, according to the criteria proposed by current consensus statements and to study the respective impact on self-reported physical performance.Material and methodsThis study included 1405 participants from the Berlin aging study II (BASE-II). The appendicular skeletal muscle mass index (SMI) was assessed with dual energy X-ray absorptiometry (DXA), muscle strength was measured by hand grip strength and the timed up and go” test (TUG) was performed as a functional parameter to reflect mobility.ResultsThe prevalence of sarcopenia was 24.3 % in terms of reduced SMI only and considerably lower for sarcopenia with reduced grip strength (4.1 %) and sarcopenia with limited mobility (2.4 %). Only 0.6 % of the participants fulfilled all three criteria. Of the subjects with a normal SMI, 8.6 % had reduced grip strength and 5.1 % had limited mobility, whereas 1.3 % subjects fulfilled both criteria. Participants with reduced strength or function reported severe difficulties in performing physical tasks significantly more often than participants with normal or reduced SMI alone (p <0.029–p <0.0001).ConclusionIn BASE-II low skeletal muscle mass was much more frequent than reduced grip strength or poor function. Reduced strength and function were found to be associated with a greater impact on physical performance than reduced muscle mass. Low SMI does not seem to be a prerequisite for low strength or limitations in mobility.ZusammenfassungHintergrundSarkopenie beschreibt den altersassoziierten Verlust von Muskelmasse, -kraft und -funktion. Ziel dieser Studie war es, die Sarkopenieprävalenz in einer Stichprobe zu Hause lebender Senioren nach verschiedenen, gegenwärtig empfohlenen Kriterien zu bestimmen und einen Zusammenhang mit subjektiver physischer Leistungsfähigkeit in Aktivitäten des täglichen Lebens zu erforschen.Material und MethodeUntersucht wurden 1405 Teilnehmer der Berliner Altersstudie II (BASE-II). Appendikuläre Skelettmuskelmasse und Skelettmuskelmasseindex (SMI) wurden mittels Doppel-Röntgen-Absorptiometrie (DXA) bestimmt. Die Muskelkraft wurde als Greifkraft gemessen, und die Mobilität als funktioneller Parameter mit dem Timed-up-and-go-Test (TUG) eingeschätzt.ErgebnisseDie Prävalenz der Sarkopenie betrug 24,3 % bezogen auf einen niedrigen SMI als alleiniges Kriterium und zeigte sich erheblich niedriger in Kombination der Kriterien niedriger SMI und reduzierte Greifkraft (4,1 %) oder niedriger SMI und eingeschränkte Mobilität (2,4 %). Nur 0,6 % aller Teilnehmer erfüllten alle 3 Kriterien. Von Teilnehmern mit normalem SMI hatten 8,6 % eine reduzierte Greifkraft und 5,1 % eine eingeschränkte Mobilität. Im Vergleich zu Teilnehmern mit normaler Kraft oder Funktion gaben jene mit reduzierter Kraft oder Funktion signifikant häufiger Schwierigkeiten in der physischen Performance an (p <0,029–p <0,0001).DiskussionEine reduzierte Skelettmuskelmasse zeigte sich erheblich häufiger als eine reduzierte Greifkraft oder eingeschränkte Mobilität. Ein niedriger SMI scheint keine Voraussetzung zu sein für eine verringerte Muskelkraft oder -funktion, die ihrerseits einen stärkeren Zusammenhang mit der subjektiven physischen Leistungsfähigkeit von Senioren aufwiesen als eine reduzierte Muskelmasse.

Hauterkrankungen beim geriatrischen Patienten

ZusammenfassungIn den letzten Jahren hat die Inzidenz altersassoziierter Hauterkrankungen, insbesondere entzündlicher Dermatosen, Autoimmunerkrankungen, Tumoren und paraneoplastischer Syndrome progredient zugenommen. Diese bedeutende Entwicklung liegt in einer erhöhten Früh- und lebenslangen UV-Exposition sowie im demographischen Alterungsprozess begründet. Um den demographischen Wandel zukünftig als Chance zu erleben, sind ein besseres Verständnis der Pathomechanismen dieser speziellen Erkrankungen sowie eine frühzeitige Diagnose und Therapie essenziell. Darüber hinaus muss die breite Öffentlichkeit für diesen Themenkomplex sensibilisiert und der Patient individuell aufgeklärt werden. Diese Strategie beinhaltet frühzeitige, prophylaktische Maßnahmen und eine konsequente Überwachung von Hochrisikogruppen. In der vorliegenden Arbeit wird die erwähnte Beziehung zwischen Hautalterung und der Epidemiologie assoziierter Erkrankungen unter Berücksichtigung der Risikofaktoren im Detail dargestellt.AbstractThe incidence of skin diseases more common in older patients, e.g. inflammatory and autoimmune diseases, benign and malignant tumors and paraneoplastic syndromes, is increasing worldwide rapidly mainly due to early or lifelong UV-overexposure and to an aging population. In order to transform this demographic change into a chance a better understanding of the pathomechanisms of these diseases, an early diagnosis and therapy are essential steps. In addition, a joint effort to raise public awareness, patient education, preventive measures and consistent monitoring of high-risk groups is of great importance. In this article, the relationship between aging and associated skin diseases will be presented with a particular focus on the epidemiology and risk factors.The incidence of skin diseases more common in older patients, e.g. inflammatory and autoimmune diseases, benign and malignant tumors and paraneoplastic syndromes, is increasing worldwide rapidly mainly due to early or lifelong UV-overexposure and to an aging population. In order to transform this demographic change into a chance a better understanding of the pathomechanisms of these diseases, an early diagnosis and therapy are essential steps. In addition, a joint effort to raise public awareness, patient education, preventive measures and consistent monitoring of high-risk groups is of great importance. In this article, the relationship between aging and associated skin diseases will be presented with a particular focus on the epidemiology and risk factors.

Patient Empowerment Improved Perioperative Quality of Care in Cancer Patients Aged ≥ 65 Years – A Randomized Controlled Trial

Purpose This randomized controlled, clinical prospective interventional trial was aimed at exploring the effect of patient empowerment on short- and long-term outcomes after major oncologic surgery in elderly cancer patients. Methods This trial was performed from February 2011 to January 2014 at two tertiary medical centers in Germany. The study included patients aged 65 years and older undergoing elective surgery for gastro-intestinal, genitourinary, and thoracic cancer. The patients were randomly assigned to the intervention group, i.e. patient empowerment through information booklet and diary keeping, or to the control group, which received standard care. Randomization was done by block randomization in blocks of four in order of enrollment. The primary outcome were 1,postoperative length of hospital stay (LOS) and 2. long-term global health-related quality of life (HRQoL) one year postoperatively. HRQoL was assessed using the EORTC QLQ C30 questionnaire. Secondary outcomes encompassed postoperative stress and complications. Further objectives were the identification of predictors of LOS, and HRQoL at 12 months. Results Overall 652 patients were included. The mean age was 72 ± 4.9 years, and the majority of patients were male (68.6%, n = 447). The ^median of postoperative length of stay was 9 days (IQR 7–14 day). There were no significant differences between the intervention and the control groups in postoperative LOS (p = 0.99) or global HRQoL after one year (women: p = 0.54, men: p = 0.94). While overall complications and major complications occurred in 74% and 24% of the cases, respectively, frequency and severity of complications did not differ significantly between the groups. Patients in the intervention group reported significantly less postoperative pain (p = 0.03) than the control group. Independent predictors for LOS were identified as severity of surgery, length of anesthesia, major postoperative complications, nutritional state, and pre-operative physical functional capacity measured by the Timed Up and Go-test by multiple robust regressions. Conclusion Patient empowerment through information booklet and diary keeping did not shorten the postoperative LOS in elderly onco-surgical patients, but improved quality of care regarding postoperative pain. Postoperative length of stay is influenced by pre-operative nutritional state, pre-operative functional impairment, severity of surgery, and length of anesthesia. Trial Registration Clinicaltrials.gov. Identifier NCT01278537