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PubMed2000

Parkinson's disease and the ability to drive.

Criteria for assessment of the ability to drive in Germany are based on guidelines published by the Gemeinsamer Beirat für Verkehrsmedizin and incorporated into the legislation. Decisions relating to the ability to drive must always be taken on an individual basis. In parkinsonian patients the ability to drive is very often impaired by motor symptoms, psychiatric complications, multimorbidity, increased daytime sleepiness and especially by cognitive disturbances. Increased daytime tiredness is common in Parkinson's disease with additional sedative effects of all dopaminergic agents (e. g., pramipexole, ropinirole). Unwanted falling asleep (e. g., at the wheel) can be avoided if notice is taken of the early signs of tiredness. A recommendation is included how to advise patients with Parkinson's disease treated with a dopamine agonist regarding the ability to drive.

Automobile Driving↗

PubMed2003

[Impact of age on postoperative events and mortality in cardiac surgery].

BACKGROUND AND OBJECTIVE: The number of "older" patients undergoing cardiac surgery is steadily increasing. In the year 2000, 37% of all patients who underwent a cardiac operation in Germany were > or = 70 years. Looking at data from our institution, we analyzed the impact of age on postoperative events and mortality in cardiac surgery. PATIENTS AND METHODS: Data from 7,048 patients who underwent cardiac surgery in our institution from January 1996 until January 2002 were analyzed. For all patients, EuroSCORE and the corresponding age-stripped value were calculated. All recorded postoperative complications and 30-day mortality were statistically analyzed. RESULTS: EuroSCORE as well as the age-stripped EuroSCORE showed a significant rise with increasing age in the total number of patients as well as in the patients, who did not die during the first 30 days after the operation. 30-day mortality and the incidence of postoperative complications increased significantly with age. While the EuroSCORE showed a significant age-dependent increase in patients who died within 30 days after the operation, the age-stripped EuroSCORE did not reveal a significant discrepancy in mortality with respect to age. CONCLUSION: Our data confirm that the age alone of a patient undergoing cardiac surgery has to be regarded as one of the important independent risk factors for mortality. In order to limit mortality in the steadily growing number of older and multimorbid patients undergoing cardiac surgery, exceptional emphasis has to be put on patient selection and therapeutic measures to improve preoperative status.

Age Factors↗

PubMed2004

[Interventional therapy of peripheral arterial disease-potentials and limitations].

The technical success rate of endovascular interventions in order to improve perfusion in peripheral arterial disease in the lower extremities has been markedly improved in the last decade due to clinical application of new recanalization techniques like application of hydrophil-coated guide wires, implantation of stents or stent grafts. If the-even long-segment-obstruction can be recanalized, the interventional radiologist is able to open the arterial vessel sufficiently. The excellent immediate results are limited in the long term by recurrent stenoses, which appear in different rates according to the vascular region. Whereas recurrent stenoses have nearly no clinical significance in the aortoiliac vascular segment due to the size of the treated vessels and the excellent flow, there is a significant amount of restenoses in the femoropopliteal segment and, even more, in the tibial arteries. This leads to a different indication of endovascular therapy according to the segment treated. However, in an interdisciplinary consensus we offer primary endovascular therapy for treatment of aortoiliac obstruction to all patients, whereas lesions at the femoral bifurcation are a clear primary indication for open surgical treatment. In the femoropopliteal segment, we choose a primary endovascular procedure with respect to the length of the occlusion, patient's risk factors and comorbidities. Yet, longer obstructions are a clear indication for primary surgical treatment. In cases of infrapopliteal disease, we recommend an endovascular treatment as the initial option due to the reduced invasiveness of the predominantly old and multimorbid patient cohort. Further clinical research for the evaluation of endovascular therapeutic measures in peripheral arterial disease urgently requires outcome studies, which include clinically relevant endpoints to better define the clinical value of endovascular therapy compared to traditional surgical bypass procedures. Until new clinical trials will be published, the Transatlantic Consensus document (TASC) of a variety of vascularly specialized scientific societies seems to be a helpful guideline.

Angiography↗

PubMed2006

[Percutaneously implantable aortic valve: the JenaValve concept evolution].

Due to the increasing incidence of severe aortic stenosis in old and multimorbid patients, the percutaneous implantation of aortic valve-carrying stents has become an alternative to the surgical replacement of aortic valves. Starting in 1995, the authors developed a self-expanding stent which transferred the necessary forces for anchoring up to the aorta ascendens-a conception taken over from CoreValve. The further improvement of this idea over the past 11 years has led to a self-expanding, relatively short stent-valve system that is reliably positioned in the cusps of the old aortic valve and holds the old valve like a paper clip, thus transferring the holding forces physiologically. As compared to conventional systems, the sophisticated insertion catheter requires further chronic animal tests so as to represent a true alternative to the conventional surgical procedure.

Age Factors↗

PubMed2006

[What is new in the treatment of community-acquired pneumonia?].

Community-acquired pneumonia (CAP) is the most important infectious disease in Germany. After 3 years of data recording, the country-wide competence network CAPNETZ presents reliable data on etiology and course of the disease, based on more than 3,500 prospectively observed patients. In the acute phase, lethality is as high as nearly 10%, and in the 6-month follow-up period after the acute infection, lethality is > 15%. A reliable detection of the underlying pathogen is possible in less than half of all patients studied. The most frequent pathogens are Streptococcus pneumoniae (40%), Haemophilus influenzae, and Mycoplasma pneumoniae (8% each). Legionella (3%) and Chlamydia pneumoniae (< 1%) are rarely found, and gram-negative enterobacteriaceae (< 5%) are restricted to high-risk patient groups (nursing home, multimorbidity). CAPs due to pneumococci, legionella or enterobacteriaceae were associated with increased lethality. Problems with resistances had not been found in Germany, except for a decreasing susceptibility of S. pneumoniae to macrolides. Viruses could be detected in nearly 15% of all pneumonia patients. The CRB-65 score allows a reliable discrimination between patients with a high and low risk of dying. The new S3 guideline for diagnosis and treatment of CAP recommends a risk-adapted treatment. Low-risk patients shall receive a monotherapy with, e. g., amoxicillin, high-risk patients should be treated with a broad-spectrum combination therapy (beta-lactam and macrolide).

Age Factors↗

PubMed2006

[High need for improvement and many open questions in health care for palliative patients].

The health care for patients with incurable, advanced diseases is increasingly attended to in Germany. Among other things, this is enforced by the debate on euthanasia and by the criticism of the inadequate structure of services and processes of care. The palliative care approach refers to cancer as well as to non-cancer patients; due to demographic changes, it becomes more and more important for an increasing number of old and very old patients with particular complex needs (e. g., caused by multimorbidity, dementia and chronic pain). Therefore, the need for improving palliative care is immense. However, the statements on the current situation and the recommendations for improvement are based only slightly on valid scientific data. This article (written from the perspective of health services research) provides an overview on the topic with particular respect to the structure of specialized palliative care services (such as palliative care teams and palliative care units) and to the political framework. Open questions on diverse levels are picked out as a central theme, and the need for interdisciplinary, application-oriented research is pointed out.

Forecasting↗

PubMed2006

[Morbidity and health in old age. A challenge for prevention and health care].

Due to chronic illness and multimorbidity, the physical and psychosocial impairments increase significantly in the second half of life. Even though the health condition of the elderly has improved in recent years, the potential for prevention in older people is still undervalued. On the basis of surveys, data from the Association of CHI Physicians and health insurance data, this article provides a review of health and health behaviour of the elderly in Germany. It aims to point out areas of particular relevance for prevention and preventive approaches. Strategies that consider mental and social aspects of aging beside the physical ones are necessary. Systematic, personal and professional factors still inhibit the realisation of these strategies. In this context, doctors and nurses are particularly important as primary professional contact persons for the target group. However, prevention and health promotion in that age group are social tasks, which need the appropriate involvement of further professionals and an explicit political agenda setting.

Aged↗

PubMed2004

[Laparoscopic esophagotomy without diverticular resection for treating epiphrenic diverticulum in hypertonic lower esophageal sphincter].

INTRODUCTION: As a rule, epiphrenic diverticulum occurs in combination with most diverse forms of dysfunction in the lower esophageal sphincter (LES) and/or in the esophagus itself. The main symptoms are dysphagia, pain, and regurgitation. The operation consists in myotomy, diverticulum resection, and partial fundoplication via abdominal or thoracic approach using conventional or minimally invasive technique. The main risk is postoperative suture dehiscence after diverticular resection. The present study was therefore undertaken to establish whether the operation succeeds in risk patients even without resection of the diverticulum. PATIENTS AND METHODS: In the period from 1998 to 2001, six patients were investigated preoperatively by means of esophageal manometry, endoscopy, and radiological barium swallow. The four risk patients underwent only myotomy of the LES, if appropriate, in combination with laparoscopic partial fundoplication. Resection of the diverticulum by thoracoscopy or with conventional thoracic technique was also performed in the two patients with normal risk. RESULTS: Three of the four risk patients showed normal postoperative courses after laparoscopic myotomy and rapidly became free of symptoms and were able to eat normally. One patient died perioperatively of pulmonary complications. After thoracic diverticulum resection, both patients developed postoperative suture dehiscence with a complicated course. Altogether, freedom from symptoms with regard to dysphagia and regurgitation could be attained in five out of six patients over a follow-up period of 6 to 25 months. CONCLUSION: In patients with epiphrenic diverticulum and disorder of LES function, myotomy alone without resection of the diverticulum may be sufficient to relieve or eliminate symptoms. Laparoscopy and the combination with partial fundoplication are the preferred techniques. In our opinion, this method must be considered in order to reduce the surgical risk in multimorbid and elderly patients.

Aged↗

PubMed1997

[Percutaneous ultrasound controlled drainage of large splenic abscesses].

UNLABELLED: Because of the rare incidence of splenic abscesses and bleeding, only a few cases are described in the literature on percutaneous drainage of splenic abscesses. We report on eight cases (three male, five female, average age 74.1 +/- 10.76 years) of percutaneous, sonographically controlled catheter drainage of large splenic abscesses. RESULTS: Percutaneous, sonographically controlled drainage of splenic abscesses was feasible in all eight cases in the last 5 years (trocar technique, drain: 12-16 F, abscess contents 70-750 ml). In seven of eight cases, therapy with percutaneous, sonographically controlled drainage of the splenic abscess and rinsing of the abscess cavity over several days was successful. In two cases, however, a recurrent abscess had to be drained repeatedly with sonographic control, and this was successful. In one case a colitis-related fistula prevented successful drainage of an infected subcapsular splenic hematoma. The following splenectomy, however, proved the infected hematoma to be completely drained. In this study there were no complications like bleeding, injury of pleura or colon. The advantages of percutaneous drainage are: the spleen is not removed; conservative therapy is beneficial, particularly in multimorbid patients with a high surgical risk; there is no transmission of bacteria; the method is safe and effective.

Abscess↗

PubMed1999

[Laparoscopic creation of stomas--an ideal single indication in minimally invasive surgery].

The laparoscopic creation of ileostomas and colostomas can be performed in a quick, safe and technically effective manner. The advantages of the minimally invasive approach are low morbidity and mortality, minimal blood loss and fast recovery in these mostly multimorbid patients as well as shorter time of hospitalization. We report on a total of 20 patients who underwent laparoscopic creation of colostoma in 19 cases and creation of ileostoma in one case in a period of 2 years. There were no intraabdominal complications and no lethal outcome. All patients reached their preoperative level of mobilization at the 2nd postoperative day. The indications for the laparoscopic enterostomy are described.

Aged↗

PubMed2001

[Spectrum and results of operative interventions in HIV infection patients].

Owing to their number, multimorbidity, and prolonged survival following improved antiretroviral therapy, HIV-infected subjects represent an important subgroup of the patients requiring surgical treatment. The spectrum of operative interventions performed in these people comprises both characteristic diagnostic, palliative, and therapeutic measures and all the same surgical indications as in an age-matched non-HIV-infected patient population. Published data concerning the results of operative interventions in these patients are rather scarce. The surgical success rate is 68-90% for elective therapeutic measures. In 21-94% of HIV-infected patients intraoperative findings of a HIV-associated opportunistic disease are reported. Depending on patient selection and the kind of operation performed, the perioperative morbidity of these subjects was 9-87% (median 33.5%), while postoperative mortality ranged from 0 to 71% (median 8%). Particular determining factors of perioperative morbidity and mortality are the degree of individual immunosuppression and the urgency of surgical intervention. In summary, operation-associated morbidity and mortality of HIV-infected patients appear not to be significantly increased compared to non-HIV-infected patients in similar preoperative health condition. The present analysis reflects a marked improvement of operative results in HIV-infected patients during the past 20 years.

AIDS-Related Opportunistic Infections↗

PubMed2003

[Problems of pharmacotherapy of infections in the aged].

Infectious diseases play an important role in the elderly. Disease progression is often more severe, displaying a higher complication rate and causing increased mortality. Elderly patients suffer more frequently than younger under pneumonia, exacerbations of chronic bronchitis, urinary tract infections as well as skin and soft tissue infections. When starting empiric antibiotic therapy one should consider that the bacterial spectrum afflicting elderly patients may differ from that afflicting younger patients. In addition an increasing number of nosocomial and multiresistant pathogens is seen in elderly patients due to more frequent hospitalisation and living in nursing homes. Patient multimorbidity and multiple co-medications make awareness of important drug-interactions essential. The purpose of this article is to review the indications and side-effects of well-tried and newer antibiotics with respect to patients age. Especially the newer antibiotics Ertapenem, Linezolid, Quinupristin/Dalfopristin and Telithromycin are discussed in detail.

Aged↗

PubMed2003

[Drug therapy of elderly patients from the viewpoint of the clinical pharmacologist].

Polypragmasy (polypharmacotherapy) is often due to the frequent incidence of multimorbidity among elderly patients. This may evoke unpredictable drug-interactions, which often become a reason for hospitalization. Additional medications might be the consequence. Geriatric patients are often characterized by variant pharmacokinetic parameters. Individualized drug-therapy should take into consideration not only the patients' age, liver and kidney functions but also the individual variability of hepatic metabolization and drug-resorption in the intestine based on genetic polymorphisms. Summing up, it is very important to verify a consisting or a new drug-therapy concerning its risk-benefit ratio and if it is needed, to omit or change some of the medications.

Aged↗

PubMed2005

[Cardiopulmonary monitoring in gastroenterological and renal emergencies].

Predominantly elderly and multimorbide patients require frequently intensive care observation and treatment due to acute gastrointestinal and renal disease. Manifest circulatory and rhythm instability, acute heart failure and severe metabolic or electrolyte derangements present indications for submission to a critical care unit. Stabilization of vital functions, control of specific therapeutic procedures (e. g. renal replacement therapy), and early recognition of secondary complications belong to the tasks of intensive care. Beyond a baseline monitoring available procedures comprises a broad spectrum from pulseoxymetrie to pulmonary artery catheter monitoring depending of the need of the individual patient.

Acute Kidney Injury↗

PubMed2003

[The prosthesis nail -- a new stable fixation device for periprosthetic fractures and critical fractures of the proximal femur].

Increasing numbers of total hip arthroplasties in combination with increasing age and growing daily activities of the elderly lead to increasing numbers of periprosthetic fractures and revision arthroplasties in osteoporotic bone. The prosthesis nail is a hybrid of a hip prosthesis and an intramedullary nail allowing immediate full weight bearing and early rehabilitation. The prosthesis nail consists of three self-locking components: a distally locked intramedullary nail, different lengthening modules, and a hip prosthesis module. From 1992 to 1999, 28 prosthesis nails were implanted in 26 patients (40-88 years, mean age: 71 years). The indications were 21 peri- and subprosthetic fractures caused by trauma, 2 fractures of the proximal femur in combination with a fracture of the femoral head or severe degenerative arthritis, and 4 revision arthroplasties associated with poor bone quality. A combination of the prosthesis nail and bone cement was used in one patient suffering from a pathological fracture of the distal femur. Patients were additionally treated with wire cerclage (six patients) and autogenous bone grafting (ten patients). All patients-except those who received a reconstruction of the acetabulum in the same session (four patients)-were mobilized with full weight bearing on the operated side as soon as wound pain diminished. Bone healing was observed in all periprosthetic fractures. In three patients the prosthesis nail had to be revised: one patient suffered from recurrent dislocations and in one patient weighing 350 pounds limb shortening occurred after the distal locking screw broke. Intramedullary infection was observed once after treatment of a periprosthetic fracture. When bone union was achieved the prosthesis nail was removed and the patient was mobilized with a girdlestone situation. The idea of the prosthesis nail is based on the logical consequence of treating femur fractures with the most efficient procedure, which is intramedullary nailing. The prosthesis nail can be applied according to the requirements of the fracture as a reamed or unreamed nail and immediate full weight bearing is possible. Considering the high average age of the patients, low morbidity, short rehabilitation time, and low costs are the major advantages of this new device. Taking into account the unfavorable preoperative conditions associated with elderly and multimorbid patients, the rate of complications is relatively low.

Acetabulum↗

PubMed2007

[Relation between certain diseases and frequency of depression in geriatric patients].

The higher prevalence of depression in specific diseases and older persons is discussed. This prevalence varies greatly according to the method used to collect data. A risk group can only be defined if information on diseases and other influencing factors are collected uniformly. The target diagnoses Parkinson's disease, stroke, myocardial infarction, cancer, diabetes mellitus, chronic pain, multiple infarct syndrome, Alzheimer's and other dementia were recorded from 1208 geriatric patients of the ZAGF municipal hospital in Munich, Germany. Logistic regression was used to identify chronic pain as the main cofactor for an association with depression (clinical diagnoses by ICD-10) and depressive symptoms (via GDS [Geriatric Depression Scale]). This association was also found for multimorbid patients with chronic pain. Impairment of the activities of daily living and the clinical setting were important additional cofactors. Pain patients are therefore at higher risk for depression.

Activities of Daily Living↗

PubMed2006

[Insufficient involvement of psychiatrists in substitution treatment].

Results of a nationally representative study in 2,694 patients reveal that most physicians (n=223) involved in substitution treatment of opioid-dependent patients are general practitioners, while only 16% have a psychiatric/psychotherapeutic background and only 21% of the addictive patients are treated by psychiatrists. This contrasts with the remarkably complex pattern of co- and multimorbidity with other mental disorders in such patients. Most psychiatrists engaged in substitution treatment work in specialized outpatient wards (51.3%), and few were operative in their own or private practice (7.2%). Implications of these critical findings are discussed.

Comorbidity↗

PubMed1998

[Depression in the very elderly].

In the Berlin Aging Study (BASE) an age and gender stratified sample of 516 persons aged 70 to over 100 was assessed by means of the semi-structured GMS-A interview, the CES-D-self-rating scale and the Hamiltion-Depression-observer-rating scale. Prevalence rates were 4.8% for Major Depression, 9.1% for all DSM III-R specified depressive disorders and 26.9% of subthreshold depression was included. There was no increase in prevalence rates with age but an increase in scores on the self rating CES-D. The prevalence rates for DSM III-R specified depression in females was 10.3% and almost double that of men (5.6%). Depressed persons do not show significant cognitive impairment as measured with the MMSE in comparison to controls. As compared to the total sample higher prevalence rates of overall depression were seen in persons with multimorbidity (36.8%) and lower rates in married persons. 13.2% of the elderly talked about feeling tired with life, 7.9% had thoughts about death and 1.2% reported suicidal ideation, which was closely linked to depressive disorders. In 44% of depressed cases undertreatment was observed. Only 6% got Antidepressants but 40% benzodiazepines.

Aged↗