Tania Zieschang

Dual-task performances can be improved in patients with dementia A randomized controlled trial

Background: Deficits in attention-related cognitive performance measured as dual-task performance represent early markers of dementia and are associated with motor deficits and increased risk of falling. The purpose of this study was to examine the effect of a specific dual-task training in patients with mild to moderate dementia. Methods: Sixty-one geriatric patients with confirmed dementia took part in a 12-week randomized, controlled trial. Subjects in the intervention group (IG) underwent dual-task–based exercise training. The control group (CG) performed unspecific low-intensity exercise. Motor performance (gait speed, cadence, stride length, stride time, single support) and cognitive performance (serial 2 forward calculation [S2], serial 3 backward calculation [S3]) were examined as single and dual tasks. Decrease in performance during dual tasks compared to single task expressed as motor, cognitive, and combined motor/cognitive dual-task cost (DTC) was calculated before and after intervention. Primary outcome was defined as DTC for gait speed under complex S3 conditions. Results: Specific training significantly improved dual-task performance under complex S3 conditions compared to the CG (reduction of DTC: gait speed 21.7% IG, 2.6% CG, p < 0.001; other gait variables: 8.7% to 41.1% IG, −0.9% to 8.1% CG, p ≤ 0.001 to 0.056; combined motor/cognitive: 20.6% IG, 2.2% CG, p = 0.026). No significant effects were found under less challenging dual-task S2 conditions or for cognitive dual-task S3 performance. Conclusions: The specific exercise program was effective to improve dual-task performance in patients with dementia. Classification of evidence: This study provides Class II evidence that specific dual-task training improves dual-task performance during walking under complex S3 conditions in geriatric patients with mild to moderate dementia.

Physical Training Improves Motor Performance in People with Dementia: A Randomized Controlled Trial

To determine whether a specific, standardized training regimen can improve muscle strength and physical functioning in people with dementia.

Improving care for patients with dementia hospitalized for acute somatic illness in a specialized care unit: a feasibility study.

BACKGROUND Persons with dementia hospitalized for an acute illness have a high risk of poor outcomes and add to the burden on acute care systems. We developed a segregated Special Care Unit (SCU) in a somatic hospital for patients with challenging behavior resulting from dementia and/or delirium. This pilot study evaluates the feasibility and patient outcomes. METHODS The SCU was established with environmental features that allow for safe and unrestricted ambulation within the unit and create a home-like atmosphere. Daytime activities structure the day and assure additional professional presence. The staff received intensive specialized training. Feasibility criteria were: acceptance by the staff, avoidance of transfers to geriatric psychiatry, lack of serious falls and mortality. Patient outcome criteria were ADL (Barthel index), mobility scores and behavior scores (Wilcoxons, McNemar tests, pre-post design). RESULTS 332 consecutively admitted patients were enrolled. The SCU has been well received by the staff. Length of hospital stay did not differ from other hospital patients (15.3 +/- 8.3 vs. 15.0 +/- 10.3 days, p = 0.54). Six patients were transferred to geriatric psychiatry. Two patients suffered a fall-related hip fracture. The median Barthel Index improved significantly (admission 30, discharge 45, p < 0.001), with only 8.5% of patients suffering functional loss. Wandering, aggression and agitation were significantly reduced (p < 0.001). CONCLUSIONS The SCU has improved the care of patients with challenging behavior. Decline in ADL function and institutionalization occurred to a lesser degree than would be expected in this group of patients. Despite the selection of patients with behavioral problems, transfer to psychiatry was rare.

Feasibility and accuracy of fall reports in persons with dementia: a prospective observational study

BACKGROUND The feasibility, test-retest reliability, and accuracy of different fall recording methods have not been studied in older persons with dementia. METHODS This was a prospective observational study, nested within a randomized controlled trial on motor training, in which 110 participants were monitored for falls over 12 months. Seven methods of fall recording were compared: face-to-face interviews; phone interviews: weekly for three months, monthly for 9 months, a final interview after 12 months; prospective calendar method; interviews with a proxy and the general practitioner (GP). Summing the count of falls and removing duplicate reporting of the same fall was found to provide the best approximation of the actual number of falls and was chosen as the criterion-standard. RESULTS The combination of calendar method and phone interviews showed the highest accuracy (74% of falls, 93% of fallers). As a single measure, weekly phone calls were superior to calendars or proxy-report. Monthly phone calls recorded only half the falls that were picked up by weekly calls (p = 0.002) and were inferior to the calendars (p<0.001) and proxy-report (p = 0.015). GPs knew of only 14% of falls and 19% of fallers. In addition, 49% of subjects who documented a fall prospectively did not recall a fall after 12 months. CONCLUSION The combination of fall calendars with regular telephone interviews can be recommended for persons with mild to moderate stage dementia. If feasible, recall periods should be as short as one week; additional information by care-givers increases accuracy of reports. Retrospective recall of falling with long recall periods is not recommended.

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.

Sustainability of Motor Training Effects in Older People with Dementia

Evidence for sustainability of motor training effects in people with dementia is lacking. To examine whether the substantial improvements in motor performance achieved through a three-month specialized, standardized motor training were sustained, the participants of the randomized controlled trial were re-evaluated nine months after training had ceased. As part of a comprehensive study, participants with confirmed mild to moderate dementia underwent a progressive resistance and functional group training specifically developed for patients with dementia (intervention, n = 40) compared to a low-intensity motor placebo activity (control, n = 51). Primary and secondary outcome measures for maximal strength and function were measured before the start of the training (T1), directly after training ceased (T2), three months after training ceased (T3) and-the focus of this paper-nine months after training ceased (T4). Even after nine months without training, the gains in functional performance were sustained with significant group differences in the primary endpoint (five-chair-rise, relative change: IG: -8.54 ± 22.57 versus CG: +10.70 ± 45.89 s, p = 0.014, effect size ηp2 = 0.067). Other functional tests, such as walking speed and POMA (Tinetti), confirmed this result in the secondary analysis. Strength, as measured by the primary endpoint 1-Repetition Maximum (1RM) was still elevated (time effect for T1 versus T4: 148.68 ± 57.86 versus 172.79 ± 68.19 kg, p < 0.001, effect size ηp2 = 0.157), but between-group differences disappeared (relative change: maximal strength, IG: 22.75 ± 40.66 versus CG: 15.60 ± 39.26, p = 0.369). The study found that intensive dementia-specific motor training sustainably improved functional performance of patients with dementia nine months after cessation of training.

A special care unit for acutely ill patients with dementia and challenging behaviour as a model of geriatric care

ZusammenfassungDieser Artikel beschreibt die Entwicklung eines innovativen Versorgungskonzepts zu Behandlung von Menschen mit Demenz, die in einem somatischen geriatrischen Krankenhaus stationär behandelt werden. Es wurde ein halb-geschlossener geschützter Spezialbereich für Patienten mit herausforderndem Verhalten eingerichtet, welches durch eine Demenz, eine Delir oder ein Delir bei Demenz bedingt ist. Innerhalb des Bereiches sind die Patienten in ihrer Mobilität nicht eingeschränkt. Die Milieugestaltung erzeugt eine möglichst wohnliche Atmosphäre. Tagesstrukturierende Maßnahmen führen zu Aktivierung und gewährleisten zusätzliche professionelle Präsenz. Es erfolgte eine intensives Schulungsprogramm für die Mitarbeiter. GISAD ist im Krankenhaus gut angenommen und wird als eine Verbesserung der Patientenversorgung angesehen. Die psychologische Belastung der Pflegenden hat trotz Selektion dieser schwierigen Patienten im Verlauf eines Jahres nicht zugenommen.AbstractThis paper describes the development and management of a new model of care for hospitalized patients with challenging behaviour evoked by dementia and/or delirium. To ameliorate care for patients with dementia in a geriatric acute care hospital a segregated Special Care Unit for patients with challenging behaviour was created. Environmental features allow for safe and unrestricted ambulation within the unit and create a home-like atmosphere. Day-time activities structure the day and assure additional professional presence in the unit. An intensive training program for the staff was provided. The SCU has been well accepted by the staff and is considered to be an improvement in care. Psychological burden of the nurses did not increase over a time period of one year in caring for these difficult patients.

Treatment quality in geriatric patients with diabetes mellitus in various home environments

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.

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.

Carpal tunnel syndrome in diabetes mellitus

ZusammenfassungDas Karpaltunnelsyndrom (KTS) tritt gehäuft bei Patienten mit Diabetes mellitus auf. Seine Prävalenz liegt bei gleichzeitig vorhandener diabetischer Polyneuropathie doppelt so hoch wie bei Patienten, bei denen keine diabetische Erkrankung bekannt ist (30% vs. 14%). Ein KTS scheint aber auch ein Prädiktor für das Auftreten eines späteres Diabetes mellitus zu sein, denn Patienten mit einem neu aufgetretenen Diabetes waren in den vorausgehenden Jahren fast 1,4-mal so häufig von einem KTS betroffen wie ihre nichtdiabetischen Altersgenossen.Im vorliegenden Beitrag werden Diagnostik, Differentialdiagnostik und Besonderheiten der Therapie des KTS bei Menschen mit Diabetes beschrieben. Bei der lokalen oder oralen Applikation von Kortikoiden sollte die anhaltende Erhöhung der Blutglucosewerte bedacht werden und ggf. eine Intensivierung der Diabetestherapie erfolgen. Bei einem Fortschreiten des KTS ist die operative Entlastung die Therapie der Wahl.AbstractThe carpal tunnel syndrome (CTS) occurs frequently in patients with diabetes mellitus. The prevalence of CTS is higher in diabetic patients with peripheral polyneuropathy compared to patients with diabetes, who do not have diabetes-related late complications (30% vs. 14%). Moreover, CTS seems to be a risk factor for later manifestation of diabetes mellitus, as patients with newly diagnosed diabetes showed CTS manifestation 1.4-fold more often than the age-matched reference population.This paper describes the diagnostics, differential diagnostics and particularities in the therapy of patients with both CTS and diabetes. In case of oral or local application of corticoids, the persistent elevation of blood glucose levels has to be taken into account with potential need for intensification of diabetes therapy. In case of progression of the CTS, surgery is indicated.