[Duplication of hospitalizations of nursing home residents from 2007 to 2009--a retrospective analysis]

AIM

To demonstrate why the number of hospitalizations of nursing home residents has doubled although several studies have established that hospitalizations do not diminish their mortality rate.

METHODS

Retrospective analysis of medical databasis from 815 patients of the eight nursing homes of Zürich, thereof 180 were hospitalized in 2007, 234 in 2008 and 401 in 2009. The reasons for a hospitalization have been classified in nine categories.

RESULTS

The category "fall with fractures" with a proportion of 29% contributes most to the augmentation of hospitalizations, followed by the categories "ambiguous condition" with 24% and "improving quality of life" with 17%. Hospitalizations for the sustained optimization of quality of life explain 62% of the increased hospitalization rate.

CONCLUSION

Nursing home residents are not hospitalized to keep them longer alive, but to optimize their quality of life.

[Polypharmacy is an indicator for a poor prognosis, which is not altered by deprescribing in nursing home]

AIM

To examine the influence of polypharmacy ordered by the pretreating site and deprescribing (i.e. the appropriate withdrawal of prescribed drugs) by the nursing home physician on survival time.

METHODS

Retrospective Analysis of medical databasis from 1,249 patients, thereof 611 in a nursing home with practice of deprescribing.

RESULTS

70% of the patients with excessive polypharmacy (>9 drugs), 57% of those with polypharmacy (6 to 9 drugs) and 43% of the remaining patients (<6 drugs) deceased within 286 days after admission (chi-squared 2 DF = 43.72; p <0.001). Deprescribing by the nursing home physician at admission revealed no influence on survival time.

CONCLUSION

Polypharmacy is not the reason, but an indicator for a poor prognosis, which is not altered by deprescribing.

[Should assistance to suicide be allowed in a case of chronic persistent depression in a nursing home patient]

A 75 years old widower suffered since 26 years of many episodes of recurrent depressions. A compensated diabetes and a chronic, slowly progressive sensory-motor Neuropathy are relevant somatic comorbidities. Because of anxiety attacks complicating his progressively severe depression he could not be cared adequately in the old people home he lived in and was hospitalised. The anxiety responded well to Benzodiazepines, but the severe depression persisted despite a pharmacotherapy with Lithium, Mianserin and Citalopran. He was therefore transferred into a nursing home. There he demanded - supported by his son - an assisted suicide. 2 psychiatrists judged his wish to die as independent to his actual depression, a geronto-psychiatrist judged his suicidal ideas as a typical symptom of depression. Therefore the demanded assisted suicide was not allowed in the nursing home according to communal legal rules not allowing assisted suicide of persons with psychiatric illness in communal institutions. A hospitalisation against his own and his son's will was however not done and the assisted suicide was executed in privacy. This in Switzerland is legal even in cases of severe chronic psychiatric illness without a terminal disease.

[Cognitive impairment not due to dementia]

A 55 years old woman lived with the parents until they died. Recently, she refused to open her apartment for necessary repairs. An examination was possible only after police opened the apartment. She is in excellent physical health, has intact memory functions but reduced executive abilities. She has no delusion, but excessive fear from strangers as taught by her parents. The clinical impression of a debility is confirmed by enquiry at her relatives. The installation of a guardianship can give the necessary support for daily life.

[Basics of gerontopharmaceutic therapy and the therapy of agitation in old age]

The biggest problem of gerontopharmaceutic therapy is polypharmacy, because it potentiates side effects and malcompliance. Best practice today includes instruction of long time patients in medication self management, which includes regular use of detailed taken medication lists. In gerontopharmaceutic therapy the following substances should be avoided: anticholinergics, dopamin receptor stimulants, long acting oral antidiabetics, benzodiazepine (other then for substitution in low dose dependency, in anaesthesia or in palliative situations) and neuroleptics (other then for psychotic symptoms). In unspecific agitation with or without dementia the measure of first choice is adaption of the milieu, which may be supported by the prescription of a sedative non tricyclic antidepressive medication.

[The physicians role in a quarreling family of a demented patriarch]

The physician of a demented patient whose wealth is disputed by two fractions of his quarreling familiy had to examine his power of judgement and his ability to controll authorized persons. The courts up to the supreme court of Switzerland based their decisions on the physisians findings. Physicians have to base their opinion on carefull examination of the patients mental ability to understand and reason the contested issues.

[Geriatric house calls: into the nursing home via FFE?]

Anhand einer Fallbeschreibung wird die Problematik, welche die Betreuung von Demenzkranken für die betreuenden Angehörigen bedeuten kann, aufgezeigt. Es kann zu Belastung kommen, die für letztere kaum mehr zu ertragen sind. Wegen fehlender Krankheitseinsicht lehnen die Patienten oft jegliche fremde Hilfe wie auch medizinische Abklärungen strikte ab. Können keine Angehörigen (mehr) die Angelegenheiten des Demenzkranken vertreten, muss als gesetzliche Vertretung ein Beistand ernannt werden. Droht wegen mangelnder Versorgung vitale Gefährdung, kann ein Demenzkranker als ultima ratio per Fürsorgerischen Freiheitsentzug (FFE) institutionalisiert werden.

[Psychogeriatric emergency house call]

Der Mini-Mental-Status und das Zeichnen einer Uhr sind auch anlässlich eines Hausbesuchs geeignete Instrumente, um bei Verdacht auf Demenz Defizite zu belegen. Mit dem Uhrtest lassen sich v.a. die für die Alltagsbewältigung entscheidenden Exekutivfunktionen untersuchen. Das Errichten einer Beistandschaft ermöglicht es oft, Demenzkranke, die den Alltag nicht mehr richtig bewältigen können, weiterhin zu Hause zu betreuen, da der Beistand die dafür nötige Hilfe organisieren und koordinieren kann.

[Indication for terminal sedation]

Anhand eines Fallberichts wird die Problematik der Behandlung von geriatrischen Patienten mit mehreren potentiell letalen Erkrankungen, akuten schweren Beschwerden und Sterbewunsch erörtert. Als angemessene palliative Massnahme in solchen Situationen wird die terminale Sedation beschrieben.

Molecular evidence for Mycobacterium avium subspecies paratuberculosis (MAP) in Crohn's disease correlates with enhanced TNF-alpha secretion

BACKGROUND

Support for a role of Mycobacterium avium subspecies paratuberculosis in Crohn's disease is largely based on epidemiological evidence, as no data on mechanisms linking the presence of M. avium subspecies paratuberculosis with gut damage is available.

AIMS

To determine whether the presence of M. avium subspecies paratuberculosis contributes to the pathogenesis of Crohn's disease by promoting cytokine secretion within gut mucosa.

PATIENTS AND METHODS

A total of 235 subjects were recruited: 63 with Crohn's disease, 53 with ulcerative colitis, 45 with irritable bowel syndrome and 74 normal controls. M. avium subspecies paratuberculosis status was defined by nested PCR using IS900 sequence. Gut mucosal organ cultures were established to detect cytokine secretion patterns.

RESULTS

Significantly higher tumour necrosis factor-alpha concentrations were found in culture supernatants for Crohn's disease compared to ulcerative colitis (p<0.05), irritable bowel syndrome (p<0.01) and controls (p<0.0001). When tumour necrosis factor-alpha levels were correlated with the presence of M. avium subspecies paratuberculosis, significantly greater concentrations were only found in M. avium subspecies paratuberculosis-positive Crohn's disease patients (p<0.05). Tumour necrosis factor-alpha levels in M. avium subspecies paratuberculosis-positive Crohn's disease were significantly higher than in M. avium subspecies paratuberculosis-positive ulcerative colitis (p<0.01), M. avium subspecies paratuberculosis-positive irritable bowel syndrome (p<0.05) and M. avium subspecies paratuberculosis-positive controls (p<0.01) and all M. avium subspecies paratuberculosis-negative specimens.

CONCLUSIONS

The data link M. avium subspecies paratuberculosis with a pathogenic mechanism in Crohn's disease and is consistent with abnormal macrophage handling of M. avium subspecies paratuberculosis.

Caregivers' adaptation to change: the impact of increasing impairment of persons suffering from dementia on their caregivers' subjective well-being

As progressive dementia involves changes in patients' behaviour and cognitive and functional abilities, dementia caregiving can be considered as a process that demands continuous adaptation to change. The current intervention study investigated associations between the course of dementia patients' impairment and their caregivers' well-being over two years. One hundred and twenty-eight care recipient-caregiver dyads participated in a controlled randomised intervention study (psycho-educational group intervention), 99 dyads in which the care recipients still lived at home participated in the second assessment, and 75 dyads in the third assessment. Caregivers were interviewed about their subjective well-being (emotional well-being and life satisfaction) as well as care recipients' behavioural problems and functional disability. Care recipients completed various neuropsychological tests. The assessments were repeated one and two years later. The psycho-educational intervention had a positive impact on caregivers' well-being. Level and increase in behavioural problems and increases in cognitive and functional impairment negatively affected caregiver well-being over time. For participants from the control condition the negative association between increase in impairment and decrease in caregiver well-being over time was stronger than for the caregivers in the intervention group. Our results suggest that it is not only the severity of current problems and stress, but also the rate of change, that is important for caregivers' well-being. Psycho-educational group intervention may help caregivers to adapt to the increasing impairment of care recipients with dementia.