A multifactorial interdisciplinary intervention to prevent functional and mobility decline for more participation in (pre-)frail community-dwelling older adults (PromeTheus): study protocol for a multicenter randomized controlled trial

Background

Age-related decline in physical capacity can lead to frailty, associated with an increased vulnerability to adverse health outcomes and greater healthcare utilization. In an aging population, effective strategies to prevent physical decline and frailty, and preserve independence are needed. Prevention programs for vulnerable community-dwelling older adults are, however, often not yet established and implemented in routine practice. Research on the feasibility, implementation, and (cost-)effectiveness of multifactorial, interdisciplinary intervention programs that take advantage of available services of healthcare providers is also limited. The main aim of this study is to evaluate the effectiveness of such an intervention program (PromeTheus) to prevent functional and mobility decline for more participation in community-dwelling (pre-)frail older adults.

Methods

The study is designed as a three-center, randomized controlled trial with a 12-month intervention period. Four hundred community-dwelling (pre-)frail (Clinical Frailty Scale score 4–6) older adults (≥70 years) will be randomized in a 1:1 ratio to the intervention group (IG) or the control group (CG). The IG will receive the PromeTheus program consisting of obligatory home-based physical exercises (Weight-bearing Exercise for Better Balance) accompanied by physiotherapists and facultative counseling services (person-environment-fit, coping with everyday life, nutrition, group-based activities) delivered via existing healthcare structures (e.g., social workers, nutritionists). The CG will receive usual care and a one-time counseling session on recommendations for physical activity and nutrition. Primary outcomes assessed at months 6 and 12 are the function component of the Late-Life Function and Disability Instrument and the University of Alabama at Birmingham Life-Space Assessment. Secondary outcomes are disability, physical capacity and activity, frailty, nutritional status, falls, fear of falling, health status, and psychosocial components. Process and economic evaluations are also conducted. Primary statistical analyses will be based on the intention-to-treat principle.

Discussion

Compared to usual care, the PromeTheus program is expected to result in higher function and mobility, greater independence and lower need for care, and more participation. As the PromeTheus program draws on existing German healthcare structures, its large-scale translation and delivery will be feasible, if evidence of (cost-)effectiveness and successful implementation can be demonstrated.

Trial registration

German Clinical Trials Register, . Registered on March 11, 2021.

Care challenges in older general hospital patients : Impact of cognitive impairment and other patient-related factors

BACKGROUND

Older general hospital patients, particularly those with cognitive impairment, frequently experience adverse events and other care complications during their stay. As these findings have so far been based on small and selected patient samples, the aim of the present study was to provide reliable data on a) the prevalence of adverse care issues (summarized under the term care challenges) in older general hospital patients and on b) associated patient-related risk factors (e.g. cognitive impairment).

METHODS

A cross-sectional representative study comprising 1469 patients aged ≥65 years from 33 randomly selected general hospitals in southern Germany (GHoSt). Data collection included the use of different data sources, e.g. structured interviews with responsible nursing staff concerning care challenges and procedures for determining the patients' cognitive status.

RESULTS

Care challenges were statistically significantly (p < 0.001) more often reported for patients with dementia and/or delirium (87.5%) and mild cognitive impairment (47.9%) compared to cognitively unimpaired patients (24.6%). Adjusted odds ratios suggested cognitive impairment, impaired activities of daily living, receiving long-term care and unplanned admission as significant patient-related risk factors for care challenges. Furthermore, the occurrence of such issues was associated with the application of physical restraints, support from relatives, prescription of psycholeptics and specialist consultations.

CONCLUSION

The findings suggest a strong impact of different degrees of cognitive impairment on challenges in care. The results might help to design appropriate training programs for hospital staff and other interventions to prevent or reduce critical situations.

The Prevalence of Dementia and Cognitive Impairment in Hospitals

BACKGROUND

The care of elderly patients with comorbid dementia poses an increasing challenge in the acute inpatient setting, yet there remains a lack of representative studies on the prevalence and distribution of dementia in general hospitals.

METHODS

We conducted a cross-sectional study of patients aged 65 and older in randomly selected general hospitals in southern Germany. Patients were excluded if they were in an intensive care unit or isolation unit or if they were on specialized wards for psychiatry, neurology, or geriatric medicine. The findings are derived from patient interviews, neuropsychological testing, standardized rating scales, questioning of nursing staff, and the patients' medical records.

RESULTS

1469 patients on 172 inpatient wards of 33 hospitals were studied. 40.0% of them (95% confidence interval, [36.2; 43.7]) had at least mild cognitive impairment. The point-prevalence of dementing illnesses was 18.4% [16.3; 20.7]. Delirium, most often on the basis of dementia, was present in 5.1% [3.9; 6.7]. 60.0% had no cognitive impairment. Dementia was more common among patients of very advanced age, those who were dependent on nursing care, those who lived in old-age or nursing homes, and those with a low level of education. Among patients with dementia, only 36.7% had a documented diagnosis of dementia in the medical record. Patients with dementia were treated more often for dehydration, electrolyte disturbances, urinary tract infections, contusions, and bone fractures, as well as for symptoms and findings of an unknown nature, and much less often for cancer or musculoskeletal diseases.

CONCLUSION

Two out of five elderly patients in general hospitals suffer from a cognitive disturbance. Patients with severe impairments such as dementia or delirium often need special care. Guidelines and model projects offer approaches by which the inpatient care of patients with comorbid dementia can be improved.

Multifactorial intervention for hip and pelvic fracture patients with mild to moderate cognitive impairment: study protocol of a dual-centre randomised controlled trial (OF-CARE)

Background

A hip or pelvic fracture is a major fall-related injury which often causes a decline in mobility performance and physical activity. Over 40% of patients with hip fracture have cognitive impairment or dementia and poorer rehabilitation outcomes than those without cognitive impairment. In this subgroup, there is a lack of evidence on the best practices supporting recovery. The main aim of this study is to investigate the effects of a transitional care intervention after inpatient rehabilitation on physical activity and functional performance in this group of cognitively impaired patients.

Methods/design

This dual-centre, randomised controlled trial compares a multifactorial intervention with usual care as control condition. Two hundred and forty community-dwellers (≥ 65 years) with a hip or pelvic fracture and mild to moderate cognitive impairment (MMSE 17–26) are recruited at the end of inpatient rehabilitation.

The four-month intervention consists of (a) an individually tailored, progressive home exercise program and physical activity promotion delivered by professional instructors and lay instructors (two home visits per week) and (b) a long-term care counselling approach addressing unmet care needs, pleasurable activities, and caregiver issues if needed. Primary outcome parameters are physical activity, measured as daily walking duration with an accelerometer-based activity monitor (activPAL™) over 72 h, and functional performance, assessed with Short Physical Performance Battery sum scores. Secondary outcome parameters are fear of falling, fall related self-efficacy, falls, quality of life, depression and activity of daily living. Data are collected at the end of rehabilitation, before the intervention at the patient’s home (baseline), after four months (post-intervention), and seven months (follow-up). In addition to completer and intent-to-treat analyses of outcomes, economic data and incremental cost-effectiveness are analysed.

Discussion

Existing service models of volunteer services and legal counselling provided by care counsellors were considered when developing the intervention protocol. Therefore, it should be feasible to translate and deliver the intervention into real-world practice if it has been demonstrated to be effective.

Trial registration

German Clinical Trials Register, DRKS00008863 (Accessed 17 Apr 2019), ISRCTN registry, ISRCTN69957256 (Accessed 17 Apr 2019).

[Dementia friendly care services in general hospitals : Representative results of the general hospital study (GHoSt)]

BACKGROUND

Mostly model projects report on special care services and procedures for general hospital patients with cognitive impairment. The objective of this study was to determine the frequency of special care services and procedures in general hospitals on the basis of a representative cross-sectional study.

METHODS

From a list of all general hospitals in southern Germany we randomly selected a specified number of hospitals und somatic wards. The hospitals were visited and all older patients on the selected wards on that day were included in the study. Information about care services and their utilization was collected with standardized instruments.

RESULTS

A total of 33 general hospitals and 172 wards participated in the study. The patient sample included 1469 persons over 65 (mean age 78.6 years) and 40% of the patients showed cognitive impairments. The staff reported that the most frequent measures for patients with cognitive impairments concerned patients with wandering behavior (63.1%), efforts to involve the patients' relatives to help with their daily care (60.1%), conducting nonintrusive interviews to identify cognitive impairments (59.9%), allocation to other rooms (58%) and visual aids for place orientation of patients (50.6%). In accordance with earlier studies our results show that other dementia friendly services implemented in pilot projects were rare. The existing special services for patients with cognitive impairment were rarely used by the patients or their relatives.

DISCUSSION

The results demonstrate the urgent need to improve special care services and routines for identification of elderly patients with cognitive impairment and risk of delirium in general hospitals.

The 6-Item Cognitive Impairment Test as a bedside screening for dementia in general hospital patients: results of the General Hospital Study (GHoSt)

OBJECTIVE

The objective of this study was to examine the psychometric quality of the 6-Item Cognitive Impairment Test (6CIT) as a bedside screening for the detection of dementia in general hospital patients.

METHOD

Participants (N = 1,440) were inpatients aged ≥65 of 33 randomly selected general hospitals in Southern Germany. The 6CIT was conducted at bedside, and dementia was diagnosed according to DSM-IV. Nursing staff was asked to rate the patients' cognitive status, and previous diagnoses of dementia were extracted from medical records. Completion rates and validity statistics were calculated.

RESULTS

Two-hundred seventy patients had dementia. Cases with delirium but no dementia were excluded. Feasibility was 97.9% and 83.3% for patients without and with dementia, respectively, and decreased from moderate (93.8%) to severe dementia (53%). The area under the curve of the 6CIT was 0.98. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for the cutoffs 7/8 (0.96, 0.82, 0.85, 0.52, 0.99) and 10/11 (0.88, 0.95, 0.94, 0.76, 0.98). The nurse ratings and medical records information had lower validity statistics. Logistic regression analyses revealed that the 6CIT statistically significantly provided information above nurse ratings and medical records. Twenty-five and 37 additional patients were correctly classified by the 7/8 and 10/11 cutoffs, respectively.

CONCLUSION

The 6CIT is a feasible and valid screening tool for the detection of dementia in older general hospital patients. The 6CIT outperformed the nurse ratings of cognitive status and dementia diagnoses from medical records, suggesting that standardized screening may have benefits with regard to case finding. Copyright © 2016 John Wiley & Sons, Ltd.

[Primary Prevention of Impairments of Mobility Among Nursing Home Residents with Dementia]

The main aim of the study was to investigate the effectiveness of multidisciplinary guidelines in promoting the mobility of people with dementia in 20 German nursing homes. The study was based on a semi-experimental design [pre-post design with intervention (IG) and control group]. The statistical analyses revealed a significantly slower decline of the ability to walk among the residents of the IG than among the controls. With regard to other outcome measures the results were less clear.

[Prevalence of dementia and medical care in German nursing homes: a nationally representative survey]

OBJECTIVE

The study aimed to determine the prevalence of dementia and the degree of medical care among residents of nursing homes based on a nationally representative sample of nursing homes in Germany for the first time.

METHODS

Based on a probability sample of 609 long-term care institutions in Germany, we drew a sample of 86 facilities by applying a two-stage random procedure. All residents of the participating care facilities were comprehensively assessed by qualified nurses using a standardized Care and Behavior Assessment (CBA).

RESULTS

Of the 4,481 residents assessed in 58 care facilities (mean age 82.6 years;78 % female) on average 68.6 % (95 % CI: 67.0 - 69.8) were affected by a dementia-syndrome, 56.6 % by a severe dementia-syndrome. There were frequent contacts between residents and general practitioners, but provision of specialized medical care seemed to be deficient in many aspects.

CONCLUSION

People with dementia form the major group of residents in German nursing homes. The study provides important data on need for care and health care planning.

Evaluation of special and traditional dementia care in nursing homes: results from a cross-sectional study in Germany

OBJECTIVE

Two-thirds of all residents in nursing homes in Germany suffer from some type of dementia. We investigated whether or not dementia patients receiving special (segregated or partially segregated) care exhibited a better quality of life than their counterparts residing in traditional nursing homes.

METHODS

In a cross-sectional study in 28 special dementia care facilities in the city of Hamburg (admission criterion: mobile dementia patients with behaviour problems) 594 residents were compared to a group of nursing home residents with dementia (n = 573) in 11 randomly selected nursing homes who were receiving traditional integrative care. Primary features such as cognitive and functional impairment, and behaviour problems were assessed by qualified nursing staff.

RESULTS

Controlling for confounding variables, for dementia patients in special care units as compared to a reference group in traditional integrative care, the level of volunteer caregiver involvement was higher and there was more social contact to staff, fewer physical restraints, more involvement in home activities, and more frequent use of psychiatrists. There was no significant difference between the two care settings with regard to overall use of psychotropic drugs, however, residents in special dementia care used antipsychotics significantly less often and antidepressants more often.

CONCLUSIONS

Significant differences for a number of indicators of the quality of life point in favour of special dementia care. Future evaluation studies ought to examine not only the general efficacy of types of care designed especially for dementia patients but also the efficacy of the respective individual components (i.e. caregiver ratio).

Alkoholbezogene Störungen bei Menschen in Einrichtungen der stationären Altenhilfe: eine bundesweite repräsentative Studie

Fragestellung: Ziel der Studie war es, erstmals in Deutschland auf der Grundlage einer bundesweiten repräsentativen Stichprobe die Prävalenz alkoholbezogener Störungen und damit assoziierte Charakteristika in der Bewohnerschaft von Altenpflegeheimen zu ermitteln. </p><p> Methodik: Ausgehend von einer für Deutschland repräsentativen Zufallsstichprobe von 609 vollstationären Pflegeeinrichtungen (Erhebung durch TNS Infratest Sozialforschung), wurde durch ein zweistufiges geschichtetes Zufallsverfahren eine Substichprobe (Stufe 1: N=185 Heime; Stufe 2: N=86 Heime) für die vorliegende Untersuchung gewonnen. Davon nahmen 67,4 % (N=58 Heime) an der Studie teil (untersuchte Bewohnerzahl: 4.481; Durchschnittsalter: 82,6 Jahre; 78 % Frauen). Zentrales Untersuchungsinstrument war ein standardisiertes Pflege- und Verhaltensassessment (PVA), das durch qualifizierte Pflegekräfte bearbeitet wurde. Mittels des PVA wurden für alle Bewohnerinnen und Bewohner³ unter anderem die ärztlichen Diagnosen sowie der aktuelle Alkoholkonsum und Rauchen erhoben. </p><p> Ergebnisse: Im Mittel lagen bei 5,8 % der Bewohner (Spanne zwischen den Einrichtungen: 0–31 %) ärztlich diagnostizierte (lifetime) alkoholbezogene Störungen nach ICD-10: F10 vor. Aktueller riskanter Alkoholkonsum (&gt;20 g/&gt;30 g bei Frauen/Männern) wurde bei 0,3 % der Personen festgestellt. Die Wahrscheinlichkeit einer (lifetime) Alkoholdiagnose war positiv assoziiert mit: männlichem Geschlecht, jüngerem Alter, weniger sozialen Kontakten von außerhalb des Heims, geringerem Grad funktioneller Einschränkungen, tendenziell ausgeprägterer neuropsychiatrischer Symptomatik, häufigerem riskanten Alkoholkonsum sowie Rauchen und teilweise mit erhöhter somatischer Morbidität. </p><p> Schlussfolgerungen: Alkoholbezogene Störungen sind unter der Bewohnerschaft von stationären Altenpflegeeinrichtungen vergleichsweise häufig. Die Betroffenen bilden eine besondere Gruppe, die spezielle Anforderungen an Therapie und Versorgung stellt.

Alkoholmissbrauch und -abhängigkeit bei Bewohnern und Bewohnerinnen in Altenpflegeheimen

Zusammenfassung: Im Vergleich zu älteren Menschen in Privathaushalten ist der Anteil Alkoholkranker in Altenpflegeheimen überdurchschnittlich hoch. 1995/96, 1997/98 und 2002/03 in 13 Mannheimer Altenpflegeheimen (bei jeweils über 1200 Bewohnern und Bewohnerinnen) durchgeführte Querschnittsstudien ergaben, dass zu allen drei Zeitpunkten etwa 10 % der Bewohnerschaft eine ärztliche Alkoholdiagnose nach ICD 10 aufwiesen. Dabei waren - ebenfalls stabil über die Zeit - ein Viertel der Männer und 5 % der Frauen betroffen. Zu allen drei Querschnitten zeigten die Bewohner, die bei Heimeintritt eine Alkoholdiagnose hatten, im Vergleich zu den Bewohnern und Bewohnerinnen ohne Alkoholdiagnose signifikante Unterschiede bei einer Reihe von Merkmalen: Das Alter zum Zeitpunkt des Heimeintritts war bei Alkoholkranken mit 62 Jahren wesentlich niedriger im Vergleich zu Nichtalkoholkranken (78 Jahre). Über die Hälfte der Alkoholkranken, aber nur jeder vierte Nichtalkoholkranke war ledig oder geschieden. Vermutlich auch aufgrund des kleineren sozialen Netzes erhielten Alkoholkranke signifikant seltener Besuch von Verwandten und Angehörigen. Verglichen mit den ärztlichen Alkoholdiagnosen bei Heimeintritt ist die Prävalenz des aktuell von den Pflegekräften eingeschätzten Alkoholmissbrauchs mit 4,2 % (1995/96), 5.2 % (1997/98) und 2.2 % (2002/03) wesentlich niedriger. Alkoholkranke stellen eine besondere Herausforderung für die Pflegekräfte dar: Die Hälfte der Bewohner und Bewohnerinnen mit aktuellem Alkoholmissbrauch zeigte ein aggressives Verhalten und unkooperatives Verhalten gegenüber dem Pflegepersonal; bei der Gruppe ohne Alkoholmissbrauch traten diese Probleme dagegen nur bei etwa 25 % auf. Auf die Anforderungen von Alkoholkranken sind die Pflegekräfte nur unzureichend vorbereitet. Eine Schulung des Pflegepersonals im Umgang mit Alkoholkranken, eine adäquate personelle Ausstattung sowie eine konsiliarische Beratung durch qualifizierte Mitarbeiter und Mitarbeiterinnen von Suchtberatungsstellen sind dringend erforderlich.

Besondere und traditionelle stationäre Betreuung demenzkranker Menschen im Vergleich

Recent studies reveal that approximately two thirds of the residents in German nursing homes suffer from some type of moderate to severe dementia. In addition to cognitive impairments, other psychiatric symptoms and behavior problems frequently impact the quality of life of the affected residents, their fellow residents and the nursing staff. Novel concepts of nursing care for dementia patients with behavior problems have been developed against this backdrop, e. g. within the framework of the program of special care for dementia patients in Hamburg. A comprehensive course study (follow-up period: approximately six months) of a sample population of nursing home residents and consecutive admissions focused upon:the degree to which the quality of life and care for dementia patients in Hamburg differs according to the type of care given, i. e. segregative (domus philosophy), or partially segregative (integration philosophy), and the differences between the special care of dementia patients as provided in Hamburg, as opposed to the traditionally integrative care of dementia patients as practiced in the city of Mannheim. In order to gain the most complete picture possible-also for persons with severe cognitive impairments-information was collected primarily on the basis of the assessments made by qualified nursing staff. In the city of Hamburg there were advantages and disadvantages, respectively, between segregative care (domus philosophy) and partially segregative care (integration philosophy): the activity rates were higher for care in integrative than in domus environments, and could be maintained better over time. Moreover, the number of visits from relatives and their involvement in the nursing and social care was also higher for the integrative, as opposed to the domus setting. Among the residents of domus-care homes, however, significantly more biographical information was collected, and the proportion of dementia patients receiving gerontopsychiatric care also was higher. Dementia patients in these homes also received more psychotropic medication, with antidementia drugs and antidepressants being prescribed significantly more frequently and antipsychotic drugs less frequently.The comparison of the special dementia care available in Hamburg with the traditional, integrative care available to dementia patients in Mannheim revealed a number of visible indicators for the quality of life that point in favor of the model program in Hamburg. This is apparent in the more frequent expression of positive feelings, the greater number of activities fostering competency, the significant involvement of relatives and volunteers, the greater number of social contacts with the staff, fewer use of physical restraint, and better gerontopsychiatric care. Contradictory to our expectation, however, dementia patients cared for in the traditional setting exhibited fewer behavior problems over time than did their counterparts cared for within the framework of the Hamburg model.