Thorsten Nikolaus

Risk factors for functional status decline in community-living elderly people: a systematic literature review

To lay the groundwork for devising, improving and implementing strategies to prevent or delay the onset of disability in the elderly, we conducted a systematic literature review of longitudinal studies published between 1985 and 1997 that reported statistical associations between individual base-line risk factors and subsequent functional status in community-living older persons. Functional status decline was defined as disability or physical function limitation. We used MEDLINE, PSYCINFO, SOCA, EMBASE, bibliographies and expert consultation to select the articles, 78 of which met the selection criteria. Risk factors were categorized into 14 domains and coded by two independent abstractors. Based on the methodological quality of the statistical analyses between risk factors and functional outcomes (e.g. control for base-line functional status, control for confounding, attrition rate), the strength of evidence was derived for each risk factor. The association of functional decline with medical findings was also analyzed. The highest strength of evidence for an increased risk in functional status decline was found for (alphabetical order) cognitive impairment, depression, disease burden (comorbidity), increased and decreased body mass index, lower extremity functional limitation, low frequency of social contacts, low level of physical activity, no alcohol use compared to moderate use, poor self-perceived health, smoking and vision impairment. The review revealed that some risk factors (e.g. nutrition, physical environment) have been neglected in past research. This review will help investigators set priorities for future research of the Disablement Process, plan health and social services for elderly persons and develop more cost-effective programs for preventing disability among them.

Effectiveness of a multifaceted intervention on falls in nursing home residents

OBJECTIVES:   To evaluate the effectiveness of a multifaceted, nonpharmaceutical intervention on incidence of falls and fallers.

Preventing falls in community-dwelling frail older people using a Home intervention team (HIT): Results from the randomized falls-HIT trial

OBJECTIVES:  To evaluate the effect of an intervention by a multidisciplinary team to reduce falls in older peoples homes.

Assessment of nursing home residents in Europe: the Services and Health for Elderly in Long TERm care (SHELTER) study

BackgroundAims of the present study are the following: 1. to describe the rationale and methodology of the Services and Health for Elderly in Long TERm care (SHELTER) study, a project funded by the European Union, aimed at implementing the interRAI instrument for Long Term Care Facilities (interRAI LTCF) as a tool to assess and gather uniform information about nursing home (NH) residents across different health systems in European countries; 2. to present the results about the test-retest and inter-rater reliability of the interRAI LTCF instrument translated into the languages of participating countries; 3 to illustrate the characteristics of NH residents at study entry.MethodsA 12 months prospective cohort study was conducted in 57 NH in 7 EU countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands) and 1 non EU country (Israel). Weighted kappa coefficients were used to evaluate the reliability of interRAI LTCF items.ResultsMean age of 4156 residents entering the study was 83.4 ± 9.4 years, 73% were female. ADL disability and cognitive impairment was observed in 81.3% and 68.0% of residents, respectively. Clinical complexity of residents was confirmed by a high prevalence of behavioral symptoms (27.5% of residents), falls (18.6%), pressure ulcers (10.4%), pain (36.0%) and urinary incontinence (73.5%). Overall, 197 of the 198 the items tested met or exceeded standard cut-offs for acceptable test-retest and inter-rater reliability after translation into the target languages.ConclusionThe interRAI LTCF appears to be a reliable instrument. It enables the creation of databases that can be used to govern the provision of long-term care across different health systems in Europe, to answer relevant research and policy questions and to compare characteristics of NH residents across countries, languages and cultures.

Prädiktion von Mortalität und soziofunktionellen Einschränkungen nach proximalen Femurfrakturen bei nicht institutionalisierten Senioren

ZusammenfassungFragestellung. Die vorliegende Studie untersuchte für eine populationsbasierte Bevölkerungsgruppe älterer Patienten Prädiktoren der Behandlungsergebnisse nach proximalen Femurfrakturen. Patienten und Methoden. Von 234 kontaktierten Patienten gaben 217 zeitgerecht ihre schriftliche Einwilligung. In die weitere Untersuchung gingen nur die 134 Person ein, die nicht in einem Heim lebten. Alle Personen konnten nach 6 Monaten nachbefragt werden bzw.waren verstorben.Die Nachuntersuchungsrate lag bei über 90%. Die Halbjahrsmortalität lag bei 10%.Es wurden Mortalität,Mobilität und Umzug in ein Heim als Indikatoren für die Ergebnisqualität (Outcome) bewertet.Dabei wurden ausschließlich Informationen genutzt, die in der ersten Behandlungswoche in einer chirurgischen Abteilung verfügbar sind, um eine adäquate postchirurgische Therapieplanung zu ermöglichen. Als statistisches Modell wurde eine logistische Regression eingesetzt,wobei als Maß der Risikoerhöhung das Odds-Ratio (OR) berechnet wurde.Dies gibt als Faktor die Risikoerhöhung gegenüber einer Referenzkategorie an. Ergebnisse. Die wichtigsten Prädiktoren für einen Umzug in ein Heim waren Alter, Essunfähigkeit, postoperative nächtliche Unruhe, Z.n Apoplex und kognitives Defizit.Der wichtigste Prädiktor für Mobilitätseinschränkungen außer Haus war die Alltagsbewältigung vor Fraktur (Barthel-Index).Daneben waren Sturzangst und Krebserkrankungen von Bedeutung.Die wichtigsten Prädiktoren für die Mortalität waren neben dem männlichen Geschlecht, die Alltagsbewältigung vor Fraktur und die Angst erneut zu stürzen. Diskussion. Es scheint möglich, durch eine prädiktorgesteuerte Stratifizierung der Patienten bezüglich der postoperativen Behandlung von proximalen Femurfrakturen eine bessere Ressourcenallokation anzustreben. Dies kann in weiteren Untersuchungen mit dem vorgestellten Stratifizierungsinstrumenten überprüft werden.AbstractIntroduction. Surgical treatment, discharge planning and rehabilitation procedures are rarely based upon defined assessment procedures. It might therefore be useful to develop simple and reliable screening tools to identify patients for early discharge, intensified rehabilitation and limited treatment. Patients and methods. 234 patients were initially contacted.From these 217 gave informed consent.The reported study included the 134 home dwelling elderly.All patients could be contacted or died after six month. Thus,data from more than 90% could be used for the analysis.The six month mortality was 10%.A populationbased cohort of elderly patients referred to five local hospitals was tested.Mortality, institutionalisation and mobility were defined as major outcome criteria. Only information that was available during the first week of treatment was used in the model.Predictors expressed as odd ratios (OR) were calculated using logistic regression with variable selection. Results. The most important predictors for institutionalisation were age, inability to eat without assistance, postoperative night time confusion, stroke history, cognitive deficit and fear of falling.Outdoor mobility was strongly associated to the preoperative ADL performance measured as the Barthel-Index, history of malignancy and fear of falling.Sixmonth mortality was associated with male sex, the Barthel-Index and fear of falling. Discussion. It seems feasible to improve postoperative resource allocation by predictor led stratification.This need to be tested in intervention trials under the specific condition of the German health care system.

Measurement of drug compliance by continuous electronic monitoring: a pilot study in elderly patients discharged from hospital.

A pilot study to assess patient compliance with medication by using a new measurement technique, continuous electronic monitoring.

Pharmacological Treatments for Persistent Non-Malignant Pain in Older Persons

Persistent non-malignant pain is common, often neglected and under-treated among older persons. Some older adults do not complain because they consider chronic pain to be a characteristic of normal aging. Physicians have concerns regarding adverse effects of pharmacological treatment.The model of the World Health Organization for treatment of cancer pain is generally accepted and also recommended for persistent non-cancer pain. Furthermore, non-pharmacological treatment should complement drug treatment whenever possible. An initial assessment and possible treatment of underlying causes of pain are pertinent.Modern pharmacological pain management is based on non-opioid and opioid analgesics. NSAIDs are among the most widely prescribed class of drugs in the world. The new cyclo-oxygenase-2 inhibitors such as celecoxib and rofecoxib offer an alternative for the treatment of mild-to-moderate pain in patients with a history of gastric ulcers or bleeding. Paracetamol (acetaminophen) is being used widely for the management of mild pain across all age groups as it has moderate adverse effects at therapeutic dosages.For moderate pain, a combination of non-opioid analgesics and opioid analgesics with moderate pain relief properties (e.g. oxycodone, codeine, tramadol and tilidine/naloxone) is recommended. For severe pain, a combination of non-opioid analgesics and opioid analgesics with strong pain relief properties (e.g. morphine, codeine) is recommended.The least toxic means of achieving systemic pain relief should be used. For continuous pain, sustained-release analgesic preparations are recommended. Drugs should be given on a fixed time schedule, and possible adverse effects and interactions should be carefully monitored. Adjuvant drugs, such as antidepressants or anticonvulsants, can be very effective especially in the treatment of certain types of pain, such as in diabetic neuropathy. Effective pain management should result in decreased pain, increased function and improvement in mood and sleep.

Accelerated aging phenotype in mice with conditional deficiency for mitochondrial superoxide dismutase in the connective tissue

The free radical theory of aging postulates that the production of mitochondrial reactive oxygen species is the major determinant of aging and lifespan. Its role in aging of the connective tissue has not yet been established, even though the incidence of aging‐related disorders in connective tissue‐rich organs is high, causing major disability in the elderly. We have now addressed this question experimentally by creating mice with conditional deficiency of the mitochondrial manganese superoxide dismutase in fibroblasts and other mesenchyme‐derived cells of connective tissues in all organs. Here, we have shown for the first time that the connective tissue‐specific lack of superoxide anion detoxification in the mitochondria results in reduced lifespan and premature onset of aging‐related phenotypes such as weight loss, skin atrophy, kyphosis (curvature of the spine), osteoporosis and muscle degeneration in mutant mice. Increase in p16INK4a, a robust in vivo marker for fibroblast aging, may contribute to the observed phenotype. This novel model is particularly suited to decipher the underlying mechanisms and to develop hopefully novel connective tissue‐specific anti‐aging strategies.

Association of pain with behavioral and psychiatric symptoms among nursing home residents with cognitive impairment: Results from the SHELTER study

Summary Evidence from a large sample of frail elderly people in nursing homes reveals an association between pain and behavioral and psychiatric symptoms. Abstract The etiology of behavioral and psychiatric symptoms is generally considered to be multifactorial, and these symptoms often indicate a need for care or assistance, which may include the presence of uncontrolled pain. The aim of this cross‐sectional study was to assess the association of pain with behavioral and psychiatric symptoms in a population of nursing home (NH) residents with cognitive impairment in Europe. Data are from the SHELTER project, which contains information on NH residents in 8 countries. Pain was defined as any type of physical pain or discomfort in any part of the body in the 3 days before the assessment. The mean age of 2822 cognitively impaired residents entering the study was 84.1 (standard deviation 9.1) years, and 2110 (74.8%) were women. Of the total sample, 538 residents (19.1%) presented with pain. After adjusting for potential confounders, pain was significantly and positively associated with socially inappropriate behavior (odds ratio [OR] 1.37; 95% confidence interval [CI] 1.04–1.80), resistance to care (OR 1.41; 95% CI 1.08–1.83), abnormal thought process (OR 1.48; 95% CI 1.16–1.90), and delusions (OR 1.48; 95% CI 1.07–2.03). A borderline inverse association was observed with wandering (OR 0.74; 95% CI 0.55–1.00). In conclusion, this cross‐sectional study provides evidence from a large sample of frail elderly showing an association between pain and behavioral and psychiatric symptoms. Treatment models that put together assessment and treatment of pain and evaluate their effect on behavioral and psychiatric symptoms are needed.

Accelerometer-based physical activity in a large observational cohort - study protocol and design of the activity and function of the elderly in Ulm (ActiFE Ulm) study

BackgroundA large number of studies have demonstrated a positive effect of increased physical activity (PA) on various health outcomes. In all large geriatric studies, however, PA has only been assessed by interview-based instruments which are all subject to substantial bias. This may represent one reason why associations of PA with geriatric syndromes such as falls show controversial results. The general aim of the Active-Ulm study was to determine the association of accelerometer-based physical activity with different health-related parameters, and to study the influence of this standardized objective measure of physical activity on health- and disability-related parameters in a longitudinal setting.MethodsWe have set up an observational cohort study in 1500 community dwelling older persons (65 to 90 years) stratified by age and sex. Addresses have been obtained from the local residents registration offices. The study is carried out jointly with the IMCA - Respiratory Health Survey in the Elderly implemented in the context of the European project IMCA II. The study has a cross-sectional part (1) which focuses on PA and disability and two longitudinal parts (2) and (3). The primary information for part (2) is a prospective 1 year falls calendar including assessment of medication change. Part (3) will be performed about 36 months following baseline. Primary variables of interest include disability, PA, falls and cognitive function. Baseline recruitment has started in March 2009 and will be finished in April 2010.All participants are visited three times within one week, either at home or in the study center. Assessments included interviews on quality of life, diagnosed diseases, common risk factors as well as novel cognitive tests and established tests of physical functioning. PA is measured using an accelerometer-based sensor device, carried continuously over a one week period and accompanied by a prospective activity diary.DiscussionThe assessment of PA using a high standard accelerometer-based device is feasible in a large population-based study. The results obtained from cross-sectional and longitudinal analyses will shed light on important associations between PA and various outcomes and may provide information for specific interventions in older people.