Biomedical subjects
Publications and source records attributed to W von Renteln-Kruse.
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Until 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 didactic teaching were both well accepted by the students and judged as interesting and instructive.
Being 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).
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For a period of 3 consecutive years, all fall events were prospectively recorded in geriatric hospital in-patients by using a standardized protocol. The incidence was 9.1 fall events/1000 hospital days in 5946 patients, and 41.0/1000 hospital days in 1015 patients (17.0%) who actually had falls. The fall rate varied between 35.0-57.0/1000 hospital days according to the main diagnostic group. Fall events were more often recorded in men than women. Recurrent falls (> or =3 falls) which contributed 13% to the 1596 falls were recorded more frequently in male patients. The majority of fall events (73.5%) occurred in patient rooms, another 20% on the floor between the patient's bedroom and toilet/bath, or in the toilet/bath, respectively. The absolute numbers of falls during night and day were not different. However, there were different patterns in the time distribution of high fall frequencies according to the main diagnostic groups. Confusion and dehydration were recorded more frequently with fall events in patients 80 years and older, and more often in fall events during the night. Injuries due to falls which had to be treated were rare, and fall-related fractures were very rare. The average duration of in-hospital stay was longer for patients with than without falls.
The geriatric screening according to AGAST (Arbeitsgruppe Geriatrisches Basisassessment) contains functional and diagnosis related items, and risk indicators of prognostic relevance, particularly in hospitalized patients. In a retrospective, cohort study, we compared the screening results in 250 consecutive patients of geriatric in-hospital acute care, and 250 consecutive patients of geriatric in-hospital rehabilitation, as well as demographic characteristics, diagnoses, and functional status as measured by the Barthel index. There was a trend indicating the total number of positive screening findings being higher with older age. Positive correlations with age were found for hearing, leg function, and cognitive function in female patients. There were also associations between the frequencies of certain screening findings with diagnostic categories. Apart from the different official manner of admission to geriatric acute care or geriatric rehabilitation, there were differences between the cohorts in age, living place before hospitalization, discharge location, spectrum of diagnoses, and the degree of functional impairment. The screening results indicated that prognostic risk factors were not equally distributed among the study cohorts. These were, in particular, urinary incontinence, poor nutritional status, impaired cognitive function, and depressive mood. There were associations between risk frequency as indicated by the screening and complicated hospital stay, functional outcome, and death. Combined with additional data, the screening according to AGAST appears to be suitable for meaningful comparisons of different groups of geriatric patients.
There is increasing interest in home visits by phycisians, nurses or occupational therapists which offer health promotion or preventive care to older people. However, the practical performance of home visits, the targeting, and the effectiveness are ambigious. The collaboration in the EU-study 'disability prevention' gave the opportunity to recruit non-selected people 60 years and older from 14 general practitioners' patient lists in Hamburg. The study participants were offered different programs of health promotion, i. e., group sessions at the geriatric center and preventive home visits. The home visits were made by a nurse who received special training, and a curriculum was established. Seventy-seven elderly persons were visited because they were not able to attend the group sessions at the geriatric center due to self-reported problems in mobility. The investigations revealed combined risks for development of functional decline and dependency in the majority of these community dwelling elderly persons. These findings were unknown to the general practitioners. For example, the risk of falling as recorded by assessment was elevated in more than half of the persons visited. Screening and assessment are useful for planing measures of health promotion and prevention. There are still questions open to discussion. The targeting, practicability, and prerequisites in structure of service provision are considered with regard to the present study's results and an upto date literature review.
Forty-five stroke patients and their 45 proxies were interviewed after the patients' hospital admission and before discharge. The topics of the interviews were disease knowledge, expectations in and judgement about therapy, estimation of functional health status (CCOP/WONCA Charts), and prognosis. The patients and proxies were also asked to name the patient's actual three most important health problems. The depressive symptomatology in the patients (geriatric depression scale) and their ADL status (Barthel Index) were evaluated on admission and before hospital discharge. The proxies' general knowledge of disease was superior compared to that of the patients. There were knowledge deficits regarding individual risk factors and secondary prevention, in particular. Information was predominantly obtained from physicians. However, an additional need for information on prognosis and prevention, in particular, was expressed by patients and proxies before hospital discharge. There was a high agreement between the patients and their proxies in mentioning the patients' actual three most important health problems, apart from psychological problems. These were mentioned only by the proxies but not by the patients themselves. Depressive symptomatology in the patients increased significantly. There were associations of depression with the level of the Barthel Index score and the patients' self-estimation of functional health status before and after the stroke. Full recovery was expected by one half of the patients, on admission. The patients' primary therapeutic goal was the ability to walk again. Their ADL status improved significantly, as measured by a mean increase in the Barthel Index score by 22 points. The patients and their proxies, as well, judged the result of treatment equally high. The proxies' total satisfaction with patient care was significantly related to their ratings of separate parts of patient care regarding nurses, therapists, and physicians, to their expectations in therapy, and the satisfaction of their own personal needs. The results of the study revealed a particular need for information on prognosis and secondary prevention of stroke. Furthermore, depression and coping with consequences of the disease should be important issues in counselling of stroke patients and their proxies. The results regarding patient and proxy satisfaction with care were of importance for internal discussion in the clinic.
The spectrum of morbidity in older age is dominated by chronic diseases. Higher age is associated with functional difficulties, limitations, and disability. However, inter- and intraindividual variability is wide. Sequela of chronic diseases are crucial to the development of dependency and the use of health care. They are cost intensive. The number of very old people will particularly increase according to estimations of future demographic changes in Germany. It can, thus, be assumed that the need for geriatric care, specific prevention and rehabilitation will not decrease soon.
This study was done to determine the independent predictors of long-term survival and long-term functional outcome in geriatric stroke patients with a high level of co-morbidity. We prospectively recruited 302 consecutive patients transferred from local hospitals of acute care to inpatient geriatric rehabilitation with a median of 23 days after stroke. The cohort with a mean age of 75.1 (range 60-90) years was followed up for 2 years after discharge from rehabilitation. The 24 month survival rate was 71.2%. Urinary continence (p = 0.000), younger age (p = 0.000), and absence of coronary artery disease (CAD) (p = 0.039) were predictors of survival. Independence in activities of daily living (Barthel Index (BI) > or = 85) 24 months after discharge was 43.2% and predicted by an admission BI > or = 50 (p = 0.000), urinary continence (p = 0.007), and absence of CAD (p = 0.018). Good functional outcome by the Modified Rankin Scale (MRS < or = 3) 24 months after discharge was 38.4%. It was predicted by absence of CAD (p = 0.001), first-ever stroke (p = 0.014), admission BI > or = 50 (p = 0.024), urinary continence (p = 0.025), mild motor paresis (p = 0.032), and good sitting balance (p = 0.039). Our study of a relatively aged and co-morbid stroke cohort confirmed most of the well-known predictors of outcome. A new result is that CAD also seems to be an important determinant of long-term outcome.
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Explore the source record for details and available documents.
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This article describes the peculiarities of geriatric quality assurance from the view of a clinical setting. Description of structural elements of quality are well known. Improvements in process quality of individual patient care have been sustained by controlled studies on comprehensive geriatric assessment. However, implementation of results from comprehensive assessment into external rating systems for hospital accreditation/certification still needs further research. The documentation of product quality depends on the measurement of patients' independency, activities of daily living and subjective well being.
The review of medication has been recommended as an important part in preventing falls. In a random sample of 276 hospital in-patients aged 75 and over, the frequency of prescribed drugs which may increase the risk of falling by causing dizziness was assessed. Questions about dizziness and previous falls were included in a standardized questionnaire. Patients with dizziness reported falls 10 times more often than patients without dizziness. Prescribed medications possibly causing dizziness were very common. Neuroleptics, antidepressants, hypnotics/sedatives, and combinations of drugs with hypotensive efficacy were significantly more often prescribed in patients who reported dizziness. Systematical review of medications appears to be worthwhile, particularly in cases with multiple drug prescriptions.
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