Introducing a machine learning algorithm for delirium prediction-the Supporting SURgery with GEriatric Co-Management and AI project (SURGE-Ahead)

INTRODUCTION

Post-operative delirium (POD) is a common complication in older patients, with an incidence of 14-56%. To implement preventative procedures, it is necessary to identify patients at risk for POD. In the present study, we aimed to develop a machine learning (ML) model for POD prediction in older patients, in close cooperation with the PAWEL (patient safety, cost-effectiveness and quality of life in elective surgery) project.

METHODS

The model was trained on the PAWEL study's dataset of 878 patients (no intervention, age ≥ 70, 209 with POD). Presence of POD was determined by the Confusion Assessment Method and a chart review. We selected 15 features based on domain knowledge, ethical considerations and a recursive feature elimination. A logistic regression and a linear support vector machine (SVM) were trained, and evaluated using receiver operator characteristics (ROC).

RESULTS

The selected features were American Society of Anesthesiologists score, multimorbidity, cut-to-suture time, estimated glomerular filtration rate, polypharmacy, use of cardio-pulmonary bypass, the Montreal cognitive assessment subscores 'memory', 'orientation' and 'verbal fluency', pre-existing dementia, clinical frailty scale, age, recent falls, post-operative isolation and pre-operative benzodiazepines. The linear SVM performed best, with an ROC area under the curve of 0.82 [95% CI 0.78-0.85] in the training set, 0.81 [95% CI 0.71-0.88] in the test set and 0.76 [95% CI 0.71-0.79] in a cross-centre validation.

CONCLUSION

We present a clinically useful and explainable ML model for POD prediction. The model will be deployed in the Supporting SURgery with GEriatric Co-Management and AI project.

Detecting Misfolded α-Synuclein in Blood Years before the Diagnosis of Parkinson's Disease

BACKGROUND

Identifying individuals with Parkinson's disease (PD) already in the prodromal phase of the disease has become a priority objective for opening a window for early disease-modifying therapies.

OBJECTIVE

The aim was to evaluate a blood-based α-synuclein seed amplification assay (α-syn SAA) as a novel biomarker for diagnosing PD in the prodromal phase.

METHODS

In the TREND study (University of Tuebingen) biennial blood samples of n = 1201 individuals with/without increased risk for PD were taken prospectively over 4 to 10 years. We retrospectively analyzed blood samples of 12 participants later diagnosed with PD during the study to detect and amplify pathological α-syn conformers derived from neuronal extracellular vesicles using (1) immunoblot analyses with an antibody against these conformers and (2) an α-syn-SAA. Additionally, blood samples of n = 13 healthy individuals from the TREND cohort and n = 20 individuals with isolated rapid eye movement sleep behavior disorder (iRBD) from the University Hospital Cologne were analyzed.

RESULTS

All individuals with PD showed positive immunoblots and a positive α-syn SAA at the time of diagnosis. Moreover, all PD patients showed a positive α-syn SAA 1 to 10 years before clinical diagnosis. In the iRBD cohort, 30% showed a positive α-syn SAA. All healthy controls had a negative SAA.

CONCLUSIONS

We here demonstrate the possibility to detect and amplify pathological α-syn conformers in peripheral blood up to 10 years before the clinical diagnosis of PD in individuals with and without iRBD. The findings of this study indicate that this blood-based α-syn SAA assay has the potential to serve as a diagnostic biomarker for prodromal PD. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Longitudinal cognitive decline characterizes the profile of non-PD-manifest GBA1 mutation carriers

With disease-modifying treatment for Parkinson's disease (PD) associated with variants in the glucocerebrosidase gene (GBA1) under way, the challenge to design clinical trials with non-PD-manifest GBA mutation carriers (GBA1NMC) comes within close reach. To delineate trajectories of motor and non-motor markers as well as serum neurofilament light (sNfL) levels and to evaluate clinical endpoints as outcomes for clinical trials in GBA1NMC, longitudinal data of 56 GBA1NMC carriers and 112 age- and sex-matched GBA1 wildtype participants (GBA1wildtype) with up to 9 years of follow-up was analyzed using linear mixed-effects models (LMEM) and Kaplan-Meier survival analysis of clinical endpoints for motor and cognitive function. GBA1NMC showed worse performance in Pegboard, 20 m fast walking, global cognition as well as in executive and memory function at baseline. Longitudinally, LMEM revealed a higher annual increase of the MDS-UPDRS III bradykinesia subscore in GBA1NMC compared to GBA1wildtype, but comparable trajectories of all other motor and non-motor markers as well as sNfL. Kaplan-Meier survival analysis showed a significantly earlier progression to clinical endpoints of cognitive decline in GBA1NMC. Incidence of PD was significantly higher in GBA1NMC. In conclusion, our study extends data on GBA1NMC indicating early cognitive decline as a potentially characteristic feature. Comprehensive longitudinal assessments of cognitive function are crucial to delineate the evolution of early changes in GBA1NMC enabling a more accurate stratification and allow for a more precise definition of trial design and sample size.

Physical Activity, Sedentary Behavior, and Their Predictors Among Nursing Home Residents-Cross-Sectional Results of the BaSAlt Study

Little is known about physical activity (PA) and sedentary behavior (SB) among nursing home residents although PA is known as a health promoter. This study examined PA, SB, and their predictors among nursing home residents (n = 63). Dependent variables were accelerometry-based PA and SB. Predictor variables included in a path analysis were age, sex, body mass index, Barthel Index, cognitive status (Mini-Mental State Examination), physical performance (hand grip strength and habitual walking speed), and well-being (World Health Organization-5 well-being index). PA was very low (M steps per day = 2,433) and SB was high (M percentage of sedentary time = 89.4%). PA was significantly predicted by age (β = -0.27, p = .008), body mass index (β = -0.29, p = .002), Barthel Index (β = 0.24, p = .040), and hand grip strength (β = 0.30, p = .048). SB was significantly predicted by body mass index (β = 0.27, p = .008) and Barthel Index (β = -0.30, p = .012). Results might be helpful for everyday practice to identify individuals at high risk for low PA and high SB.

A 10-step participatory program for developing, implementing, and evaluating physical activity promoting actions in nursing homes in Germany

BACKGROUND

Since multidimensional barriers challenge nursing homes, a socio-ecological approach is needed for physical activity promotion in this setting. So far, little is known about how such an approach can be transferred into the successful development and implementation of PA-promoting actions together with stakeholders on-site. We aimed to investigate the actions and dimensions of PA-promoting actions and their sustainable implementation. To contribute to closing this gap, we present a 10-step program for co-developing and co-evaluating PA-promoting actions in nursing homes through an integrated counselling approach.

METHODS

We used a multiple case study approach that built upon manifold data sources, collected in 7 nursing homes over 3 years between 2021 and 2023. We collected fieldnotes and photologs from 14 future workshops (2 per home); 7 evaluation workshops (1 per home); 36 individual counsellings (2 sessions per resident), as well as 87 implementation protocols (action type and frequency), 11 evaluation questionnaires (changes among resources, cooperations, and collaborations); 7 goal attainment scales and 18 individual activity schedules. In addition, we retrieved and documented progress information at regular intervals by phone or email.

RESULTS

With staff, residents, relatives, and volunteers, we co-developed 112 ideas for PA promotion; from which 54 ideas were implemented and integrated into everyday life, differentiated into "activities of daily living," "structured activities," and "activity-friendly environments."; 18 residents in 4 homes participated in individual counselling to develop individual activity schedules. Eighteen actions were rated as "(much) more successful than expected"; 10 "(much) worse than expected," and 23 "as successful as expected." Three actions were not evaluated.

DISCUSSION

The participatory integrated counselling approach led to home-specific actions and promoted implementation into everyday life. The number and dimensions of actions implemented largely depended on the mission and vision of the respective home. The lack of staff could partially be compensated for by involving neighbourhoods, volunteers, and community organisations, such as local clubs.

CONCLUSION

To effectively promote PA in nursing homes, a tailored approach considering structural conditions, locations, volunteer engagement, and organisational visions is essential. Long-lasting partnerships and low-threshold opportunities prove promising. Future research should delve into structural-level change processes and outcomes in this context.

[Sarcopenia, physical activity and sedentary behavior among nursing home residents in Germany]

BACKGROUND

Residents in nursing homes show a high prevalence of the musculoskeletal syndrome sarcopenia and tend not to achieve current physical activity recommendations.

OBJECTIVE

The aim of this study is to identify differences in physical activity and sedentary behavior of sarcopenic residents compared with nonsarcopenic and presarcopenic residents.

METHODS

Sarcopenia assessment was performed among 63 nursing home residents in Baden-Wuerttemberg (D) using the European Working Group on Sarcopenia in Older People 2 specifications. Structured activity sessions (per week), accelerometer-based physical activity (steps/day), and sedentary behavior (percentual/day) were examined. The group comparisons were determined with Kruskal-Wallis tests and Dunn-Bonferroni post hoc tests.

RESULTS

Significant differences were found for number of steps (p = 0.005) and percentual sedentary behavior (p = 0.019). Moreover, steps per day presented significant results in group comparison for no sarcopenia (2824.4 [423-14275]) with probable sarcopenia (1703.9 [118-5663]) and confirmed/severe sarcopenia (1571.2 [240-2392]) (both p = 0.022; |r| = 0.34). Sedentary behavior demonstrated significant differences in groups with no sarcopenia (87.9% [69.1-94.3]) and with probable sarcopenia (91.7% [80.4-9835]) (p = 0.018; |r| = 0.35).

CONCLUSION

Nonsarcopenic residents demonstrated a higher number of steps and lower sedentary behavior compared with presarcopenic and sarcopenic residents. Increasing steps, reducing sedentary behavior and promoting activities of daily living can contribute to the prevention and treatment of sarcopenia in the nursing home setting.

Patterns of physical activity among nursing home residents before and during the Covid 19 pandemic-a systematic observation

BACKGROUND

The Covid-19 outbreak in spring of 2020 posed an array of challenges for nursing homes, including promoting resident physical activity (PA). Given the diversity of factors affecting resident PA, we explored how activity patterns outside weekly-scheduled structured activities changed during the pandemic and what factors promoted or inhibited PA during the pandemic.

METHODS

We conducted systematic direct observations over 823.5 h in eight nursing homes in Southern Germany in 2020 and 2021.

RESULTS

In 2020, 84.7% of person observation units were classified as sedentary (average activity level: 1.14 MET). In 2021, the percentage increased to 91.6% of observed person units (average activity level: 1.08 MET) (t = 6.947; p = .000). According to tree classification, influencing factors of PA included mealtime and daytime in 2020 and 2021, as well as presence of men residents only in 2020 and guided low threshold activities in 2021.

CONCLUSIONS

Nursing homes constitute highly sedentary places-an issue exacerbated by access restrictions for external activity experts and significant others as well as behavioural restrictions for residents during the Covid-19 pandemic. Staff could not compensate due to existing time restraints and lack of training in PA promotion. Based on our findings, we recommend future studies to develop feasible and resource-low activities to be integrated into the daily routines of nursing homes.

Older adults' coping strategies during the COVID-19 pandemic - a longitudinal mixed-methods study

Introduction

Older age is a main risk factor for severe COVID-19. In 2020, a broad political debate was initiated as to what extent older adults need special protection and isolation to minimize their risk for SARS-CoV-2 infection. However, isolation might also have indirect negative psychological (e.g., loneliness, stress, fear, anxiety, depression) or physical (e.g., lack of exercise, missing medical visits) consequences depending on individual strategies and personality traits to cope longitudinally with this crisis.

Methods

To examine the impact of individuals' coping with the pandemic on mental health, a large sample of 880 older adults of the prospective longitudinal cohort TREND study were surveyed six times about their individual coping strategies in the COVID-19 pandemic between May 2020 (05/2020: Mage = 72.1, SDage = 6.4, Range: 58-91 years) and November 2022 in an open response format. The relevant survey question was: "What was helpful for you to get through the last months despite the COVID-19 pandemic? E.g., phone calls, going for a walk, or others."

Results and Discussion

In total, we obtained 4,561 records containing 20,578 text passages that were coded and assigned to 427 distinct categories on seven levels based on qualitative content analysis using MAXQDA. The results allow new insights into the impact of personal prerequisites (e.g., value beliefs, living conditions), the general evaluation of the pandemic (e.g., positive, irrelevant, stressful) as well as the applied coping strategies (e.g., cognitive, emotional- or problem-focused) to deal with the COVID-19 pandemic by using an adapted Lazarus stress model. Throughout the pandemic emotional-focused as well as problem-focused strategies were the main coping strategies, whereas general beliefs, general living conditions and the evaluation were mentioned less frequently.

The relationship between pre-surgery self-rated health and changes in functional and mental health in older adults: insights from a prospective observational study

BACKGROUND

Elective surgeries are among the most common health stressors in later life and put a significant risk at functional and mental health, making them an important target of research into healthy aging and physical resilience. Large-scale longitudinal research mostly conducted in non-clinical samples provided support of the predictive value of self-rated health (SRH) for both functional and mental health. Thus, SRH may have the potential to predict favorable adaptation processes after significant health stressors, that is, physical resilience. So far, a study examining the interplay between SRH, functional and mental health and their relative importance for health changes in the context of health stressors was missing. The present study aimed at addressing this gap.

METHODS

We used prospective data of 1,580 inpatients (794 complete cases) aged 70 years or older of the PAWEL study, collected between October 2017 and May 2019 in Germany. Our analyses were based on SRH, functional health (Barthel Index) and self-reported mental health problems (PHQ-4) before and 12 months after major elective surgery. To examine changes and interrelationships in these health indicators, bivariate latent change score (BLCS) models were applied.

RESULTS

Our analyses provided evidence for improvements of SRH, functional and mental health from pre-to-post surgery. BLCS models based on complete cases and the total sample pointed to a complex interplay of SRH, functional health and mental health with bidirectional coupling effects. Better pre-surgery SRH was associated with improvements in functional and mental health, and better pre-surgery functional health and mental health were associated with improvements in SRH from pre-to-post surgery. Effects of pre-surgery SRH on changes in functional health were smaller than those of functional health on changes in SRH.

CONCLUSIONS

Meaningful changes of SRH, functional and mental health and their interplay could be depicted for the first time in a clinical setting. Our findings provide preliminary support for SRH as a physical resilience factor being associated with improvements in other health indicators after health stressors. Longitudinal studies with more timepoints are needed to fully understand the predictive value of SRH for multidimensional health.

TRIAL REGISTRATION

PAWEL study, German Clinical Trials Register, number DRKS00013311. Registered 10 November 2017 - Retrospectively registered, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013311 .

Longitudinal dynamics of depression in risk groups of older individuals during the COVID-19 pandemic

Background

Older individuals are most at risk of severe COVID-19 and particularly require protection causing (self)restriction of psychosocial interaction in daily living. So far, the impact of psychosocial withdrawal on mental health seems less pronounced in community-dwelling older individuals compared to younger individuals. However, dynamics and adverse long-term effects of the pandemic, such as increases in depression, are still mostly unclear, especially for vulnerable subgroups.

Methods

Pre-pandemic and 3-, 8-, 14-, 20-month peri-pandemic data were analyzed in 877 older participants (age at 3-month peri-pandemic: mean ± SD: 72.3 ± 6.3, range: 58-91 years) of the observational prospective TREND study in Germany. Severity of depression (Beck's Depression Inventory-II scores) and key factors of (mental) health were investigated for cross-sectional associations using path modeling. Risk groups defined by resilience, loneliness, history of depression, stress, health status and fear of COVID-19 were investigated for differences in depression between timepoints.

Findings

The early pandemic (3-month) severity of depression was most strongly associated with history of depression, stress and resilience. Overall increases in clinically relevant depression (mild-severe) from pre- to 3-month peri-pandemic were small (% with depression at pre-/3-month peri-pandemic: 8.3%/11.5%). Changes were most pronounced in risk groups with low resilience (27.2%/41.8%), loneliness (19.0%/28.9%), fear of COVID-19 (17.6%/31.4%), high stress (24.4%/34.2%), a history of depression (27.7%/36.9%), and low health status (21.8%/31.4%). Changes in depression were largely observed from pre- to 3-month and were sustained to the 20-month peri-pandemic timepoint, overall and in stratified risk groups defined by single and cumulative risk factors. Changes between timepoints were heterogenous as indicated by alluvial diagrams.

Conclusion

Only specific risk groups of older individuals showed a large increase in depression during the COVID-19 pandemic. Since these increases occurred early in the pandemic and were sustained over 20 months, these vulnerable risk groups need to be prioritized for counselling and risk mitigation of depression.

Frailty index and its association with the onset of postoperative delirium in older adults undergoing elective surgery

BACKGROUND

The association of frailty based on the accumulation of deficits with postoperative delirium (POD) has been poorly examined. We aimed to analyze this association in older patients undergoing elective surgery.

METHODS

Preoperative data was used to build a 30-item frailty index (FI) for participants of the PAWEL-study. Delirium was defined by a combination of I-CAM and chart review. Using logistic regressions models we analysed the association between frailty and POD adjusting for age, sex, smoking, alcohol consumption, education and type of surgery.

RESULTS

Among 701 participants (mean age 77.1, 52.4% male) median FI was 0.27 (Q1 0.20| Q3 0.34), with 528 (75.3%) frail participants (FI ≥ 0.2). Higher median FI were seen in orthopedic than cardiac surgery patients (0.28 versus 0.23), and in women (0.28 versus 0.25 in men). Frail participants showed a higher POD incidence proportion (25.4% versus 17.9% in non-frail). An increased odds for POD was observed in frail versus non-frail participants (OR 2.14 [95% CI 1.33, 3.44], c-statistic 0.71). A 0.1 increment of FI was associated with OR 1.57 [95% CI 1.30, 1.90] (c-statistic 0.72) for POD. No interaction with sex or type of surgery was detected. Adding timed-up-and-go-test and handgrip strength to the FI did not improve discrimination.

CONCLUSION

Our data showed a significant association between frailty defined through a 30-item FI and POD among older adults undergoing elective surgery. Adding functional measures to the FI did not improve discrimination. Hence, our preoperative 30-item FI can help to identify patients with increased odds for POD.

TRIAL REGISTRATION

PAWEL and PAWEL-R (sub-) study were registered on the German Clinical Trials Register (number DRKS00013311 and DRKS00012797).

Anticholinergic Drug Exposure Increases the Risk of Delirium in Older Patients Undergoing Elective Surgery

Introduction

Postoperative delirium (POD) is a common and serious adverse event of surgery in older people. Because of its great impact on patients' safety and quality of life, identification of modifiable risk factors could be useful. Although preoperative medication intake is assumed to be an important modifiable risk factor, the impact of anticholinergic drugs on the occurrence of POD seems underestimated in elective surgery. The aim of this study was to investigate the association between preoperative anticholinergic burden and POD. We hypothesized that a high preoperative anticholinergic burden is an independent, potentially modifiable predisposing and precipitating factor of POD in older people.

Methods

Between November 2017 and April 2019, 1,470 patients of 70 years and older undergoing elective orthopedic, general, cardiac, or vascular surgery were recruited in the randomized, prospective, multicenter PAWEL trial. Anticholinergic burden of a sub-cohort of 899 patients, who did not receive a multimodal intervention for preventing POD, was assessed by two different tools at hospital admission: The established Anticholinergic Risk Scale (ARS) and the recently developed Anticholinergic Burden Score (ABS). POD was detected by confusion assessment method (CAM) and a validated post discharge medical record review. Logistic regression analyses were performed to evaluate the association between anticholinergic burden and POD.

Results

POD was observed in 210 of 899 patients (23.4%). Both ARS and ABS were independently associated with POD. The association persisted after adjustment for relevant confounding factors such as age, sex, comorbidities, preoperative cognitive and physical status, number of prescribed drugs, surgery time, type of surgery and anesthesia, usage of heart-lung-machine, and treatment in intensive care unit. If a patient was taking one of the 56 drugs listed in the ABS, risk for POD was 2.7-fold higher (OR = 2.74, 95% CI = 1.55–4.94) and 1.5-fold higher per additional point on the ARS (OR = 1.54, 95% CI = 1.15–2.02).

Conclusion

Preoperative anticholinergic drug exposure measured by ARS or ABS was independently associated with POD in older patients undergoing elective surgery. Therefore, identification, discontinuation or substitution of anticholinergic medication prior to surgery may be a promising approach to reduce the risk of POD in older patients.

Outcomes of a Delirium Prevention Program in Older Persons After Elective Surgery: A Stepped-Wedge Cluster Randomized Clinical Trial

Importance

Delirium significantly worsens elective surgery outcomes and costs. Delirium risk is highest in elderly populations, whose surgical health care resource consumption (50%) exceeds their demographic proportion (15% to 18%) in high-resource countries. Effective nonpharmacologic delirium prevention could safely improve care in these vulnerable patients, but data from procedure-specific studies are insufficiently compelling to drive changes in practice. Delirium prevention approaches applicable to different surgical settings remain unexplored.

Objective

To examine whether a multifaceted prevention intervention is effective in reducing postoperative delirium incidence and prevalence after various major surgical procedures.

Design, Setting, and Participants

This stepped-wedge cluster randomized trial recruited 1470 patients 70 years and older undergoing elective orthopedic, general, or cardiac surgery from November 2017 to April 2019 from 5 German tertiary medical centers. Data were analyzed from December 2019 to July 2021.

Interventions

First, structured delirium education was provided to clinical caregivers at each site. Then, the study delirium prevention team assessed patient delirium risk factors and symptoms daily. Prevention was tailored to individual patient needs and could include: cognitive, motor, and sensory stimulation; meal companionship; accompaniment during diagnostic procedures; stress relaxation; and sleep promotion.

Main Outcomes and Measures

Postoperative delirium incidence and duration.

Results

Of 1470 included patients, 763 (51.9%) were male, and the median (IQR) age was 77 (74-81) years. Overall, the intervention reduced postoperative delirium incidence (odds ratio, 0.87; 95% CI, 0.77-0.98; P = .02) and percentage of days with delirium (intervention, 5.3%; control, 6.9%; P = .03). The effect was significant in patients undergoing orthopedic or abdominal surgery (odds ratio, 0.59; 95% CI, 0.35-0.99; P = .047) but not cardiac surgery (odds ratio, 1.18; 95% CI, 0.70-1.99; P = .54).

Conclusions and Relevance

This multifaceted multidisciplinary prevention intervention reduced postoperative delirium occurrence and days with delirium in older patients undergoing different elective surgical procedures but not cardiac procedures. These results suggest implementing this delirium prevention program will improve care and outcomes in older patients undergoing elective general and orthopedic procedures.

[Nonpharmaceutical concepts for prevention and treatment of delirium]

BACKGROUND

Cognitive impairment is common among older patients in German hospitals (40%). Dementia, other brain diseases and frailty significantly increase the risk of delirium and pose great challenges to interdisciplinary and interprofessional teams. Delirium prevention is achievable but requires complex interdepartmental strategies with specific components for timely recognition of the individual delirium risk, to carry out structured and sustained implementation of appropriate measures for delirium prevention as well as prompt etiological diagnostics and immediate treatment when delirium occurs.

OBJECTIVE

The present work aims to shed light on the role of interprofessional and interdisciplinary collaboration in evidence-based, nonpharmacological delirium prevention programs.

MATERIAL AND METHODS

Narrative review of international best practice programs.

RESULTS

Nonpharmacological prevention of delirium is effective but requires differentiated risk identification, regular delirium screening and daily targeted cognitive activation and sleep promotion. This can only be achieved in close interprofessional collaboration and is mostly carried out interdepartmentally by specialized teams.

DISCUSSION

Interprofessional multicomponent programs for delirium prevention hold the potential to reduce delirium and complication rates in older high-risk patients in regular care, thereby improving treatment and long-term quality of life. Additional interprofessional delirium prevention teams are deployed in different settings simultaneously and provide regular training on optimal delirium management. Demonstration of the effectiveness of cross-setting programs requires large multicenter studies and is therefore particularly laborious.

Autonomic Symptoms in Older Adults Are Common and Associated With Health-Related Quality of Life

Background: Autonomic symptoms are common in older adults, and a large body of literature focusing on age-related diseases shows that autonomic symptoms in these diseases constrain Health-Related Quality of Life (HRQoL). To our best knowledge, the association between autonomic symptoms in older adults, independent of specific diseases, and HRQoL has not yet been assessed. Aim: To assess the frequency and the effect of autonomic symptoms in general, as well as orthostatic intolerance, vasomotor, secretomotor, gastrointestinal, bladder, and pupillomotor symptoms, on HRQoL in older adults. Methods: Cross-sectional data of the fourth visit of the Tübinger evaluation of Risk factors for Early detection of Neurodegeneration (TREND) study were included. Autonomic symptoms, as assessed with the Composite Autonomic Symptom Score 31 (COMPASS 31), were quantified and compared with HRQoL, as assessed with the EuroQol five-level version (EQ-5D-5L). Statistical analyses included Spearman's rank correlation and multiple linear regression analysis. Results: The analysis included 928 participants with a median of 68 years; 47% were women. Of those, 85% reported at least one autonomic symptom. Gastrointestinal and secretomotor symptoms were most common. The COMPASS 31 total score and all subdomains were significantly associated with reduced HRQoL. Among the subdomains, the strongest correlations with HRQoL were found for gastrointestinal and bladder symptoms. Overall, autonomic symptoms alone explained 20% of the variance of HRQoL; when depressive mood was added, the model explained 32%. Conclusion: Autonomic symptoms are associated with HRQoL and depressive symptoms in older adults.

[Telemedicine in mobile geriatric rehabilitation : Results of the VITAAL study]

BACKGROUND

In order to implement the principle of rehabilitation before care, adaptive concepts for geriatric patients are required. Patients with visual impairments, impaired communication skills, mental illnesses or cognitive deficits are often not or only insufficiently treatable in a rehabilitation clinic. Mobile geriatric rehabilitation (MoGeRe) closes this gap in the care system, but its scope is limited. With the 22 locations in Germany, it is not possible to make a comprehensive MoGeRe possible so far. Telemedicine offers solutions here.

OBJECTIVE

Telemedicine supplements to MoGeRe in the form of video visits and video recording were examined with respect to their feasibility and acceptance in a very old target group.

METHOD

A total of 101 video visits and 26 diagnostic video recordings were carried out with 25 patients. Interviews with patients and team members were evaluated with the help of a qualitative content analysis.

RESULTS AND DISCUSSION

In particular, the acceptance of the video visit was high among all those involved. Its potential lies in the adaptation of the individual treatment, motivation, medical guidance and supervision of the team. The video recording can offer the opportunity to enrich the interdisciplinary exchange and to evaluate and adapt the therapeutic procedure. Specific strategies such as accompanying relatives, explaining the procedure and good timing are necessary for cognitively impaired patients. Our results prove that older people should also be taken into account as users of digital media.

Gut Microbiome Signatures of Risk and Prodromal Markers of Parkinson Disease

OBJECTIVE

Alterations of the gut microbiome in Parkinson disease (PD) have been repeatedly demonstrated. However, little is known about whether such alterations precede disease onset and how they relate to risk and prodromal markers of PD. We investigated associations of these features with gut microbiome composition.

METHODS

Established risk and prodromal markers of PD as well as factors related to diet/lifestyle, bowel function, and medication were studied in relation to bacterial α-/β-diversity, enterotypes, and differential abundance in stool samples of 666 elderly TREND (Tübingen Evaluation of Risk Factors for Early Detection of Neurodegeneration) study participants.

RESULTS

Among risk and prodromal markers, physical inactivity, occupational solvent exposure, and constipation showed associations with α-diversity. Physical inactivity, sex, constipation, possible rapid eye movement sleep behavior disorder (RBD), and smoking were associated with β-diversity. Subthreshold parkinsonism and physical inactivity showed an interaction effect. Among other factors, age and urate-lowering medication were associated with α- and β-diversity. Constipation was highest in individuals with the Firmicutes-enriched enterotype, and physical inactivity was most frequent in the Bacteroides-enriched enterotype. Constipation was lowest and subthreshold parkinsonism least frequent in individuals with the Prevotella-enriched enterotype. Differentially abundant taxa were linked to constipation, physical inactivity, possible RBD, smoking, and subthreshold parkinsonism. Substantia nigra hyperechogenicity, olfactory loss, depression, orthostatic hypotension, urinary/erectile dysfunction, PD family history, and the prodromal PD probability showed no significant microbiome associations.

INTERPRETATION

Several risk and prodromal markers of PD are associated with gut microbiome composition. However, the impact of the gut microbiome on PD risk and potential microbiome-dependent subtypes in the prodrome of PD need further investigation based on prospective clinical and (multi)omics data in incident PD cases. ANN NEUROL 2021;90:E1-E12.

BaSAlt - A mixed-methods study protocol on setting-based physical activity promotion and counseling in nursing homes

Introduction

Physical activity (PA) is a major contributor to healthy aging. However, physical inactivity is prevalent among the elderly in Germany, particularly in institutionalized settings such as nursing homes. This paper aims to describe the study objectives, design, methods, assessment types, collection schedules and considerations for analyzing the data within the BaSAlt study on facilitators and barriers for PA promotion in nursing homes.

Methods

We designed the BaSAlt study as a participatory intervention study with multiple measurement points in six to eight nursing homes with a total of approx. 200 residents using four main modules: (1) setting-level analysis of physical activity patterns, physical activity-related climate and physical activity-related interaction with ‘significant others,’ and organizational facilitators and barriers to physical activity, (2) physical-activity related individual-level analysis of objective and self-reported physical activity and sedentary behavior, a geriatric assessment with established procedures, assessment of people's activity and health biographies (biographical mapping) as well as their motivational, subjective well-being and distress status, and (3) a counseling module that integrates counseling at the setting level as well as individual physical activity counseling for residents. In module (4) evaluation, the effects of integrated counseling with regard to the implementation of PA promotion strategies are analyzed.

Discussion

This study will extend our knowledge of physical activity promotion in German nursing homes. Its findings will inform governmental authorities, care professionals, and academics on how to reach a particular group, characterized by inactivity, multimorbidity, and a high prevalence of dementia, residing in nursing homes, a setting that will gain further relevance in the future.

Presurgical Screening Improves Risk Prediction for Delirium in Elective Surgery of Older Patients: The PAWEL RISK Study

Introduction: The number of elective surgeries for patients who are over 70 years of age is continuously growing. At the same time, postoperative delirium (POD) is common in older patients (5–60%) depending on predisposing risk factors, such as multimorbidity, cognitive impairment, neurodegenerative disorders and other dementing disorders, and precipitating factors, such as duration of surgery. Knowledge of individual risk profiles prior to elective surgery may help to identify patients at increased risk for development of POD. In this study, clinical and cognitive risk factors for POD were investigated in patients undergoing various elective cardiac and non-cardiac surgeries.

Methods: The PAWEL study is a prospective, interventional trial on delirium prevention. At baseline, 880 inpatients at five surgical centers were recruited for sub-sample PAWEL-R. Multimodal assessments included clinical renal function, medication, American Society of Anesthesiologists (ASA) Physical Status Classification System, geriatric and cognitive assessments, which comprised the Montreal Cognitive Assessment Scale (MoCA), Trail-making Test, and Digit Span backward. Delirium incidence was monitored postoperatively by the Confusion Assessment Method (CAM) and a chart review for up to a week or until discharge. Multivariate regression models and Chi-square Automatic Interaction Detectors (CHAID) analyses were performed using delirium incidence as the primary outcome.

Results: Eighteen risk factors were investigated in elective cardiovascular and orthopedic or general surgery. A total of 208 out of 880 patients (24%) developed POD. A global regression model that included all risk variables predicted delirium incidence with high accuracy (AUC = 0.81; 95% CI 0.77, 0.85). A simpler model (clinical and cognitive variables; model CLIN-COG) of 10 factors that only included surgery type, multimorbidity, renal failure, polypharmacy, ASA, cut-to-suture time, and cognition (MoCA, Digit Span backward, and preexisting dementia), however, exhibited similar predictive accuracy (AUC = 0.80; 95% CI 0.76, 0.84).

Conclusion: The risk of developing POD can be estimated by preoperative assessments, such as ASA classification, expected cut-to-suture time, and short cognitive screenings. This rather efficient approach predicted POD risk over all types of surgery. Thus, a basic risk assessment including a cognitive screen can help to stratify patients at low, medium, or high POD risk to provide targeted prevention and/or management strategies for patients at risk.

Saving lives through life-threatening measures? The COVID-19 paradox of infection prevention in long-term care facilities

The current SARS Cov-2 infection control measures have paradoxical effects. On the one hand, the lockdown measures help to protect vulnerable populations in particular. On the other hand, these measures inevitably have the effect that those who are to be protected not only become socially isolated and are exposed to enormous psychological stress, but also break down physically due to inactivity. Thus, the activation that is omitted in the lockdown is not compensated by external reference groups, which also indicates that important conditions for healthy ageing are not given in long-term care facilities.

Impaired Executive Function and Depression as Independent Risk Factors for Reported Delirium Symptoms: An Observational Cohort Study Over 8 Years

Background

Acute medical illnesses, surgical interventions, or admissions to hospital in older individuals are frequently associated with a delirium. In this cohort study, we investigated the impact of specific cognitive domains and depression before the occurrence of delirium symptoms in an 8-year observation of older non-hospitalized individuals.

Methods

In total, we included 807 participants (48–83 years). Deficits in specific cognitive domains were measured using the CERAD test battery, and depressive symptoms were measured using Beck Depression Inventory and the Geriatric Depression Scale (GDS) before the onset of a delirium. Delirium symptoms were retrospectively assessed by a questionnaire based on the established Nursing Delirium Screening Scale.

Results

Fifty-eight of eight hundred seven participants (7.2%) reported delirium symptoms over the 8-year course of the study. Sixty-nine percent (n = 40) of reported delirium symptoms were related to surgeries. In multivariate regression analysis, impaired executive function was an independent risk factor (p = 0.034) for the occurrence of delirium symptoms. Furthermore, age (p = 0.014), comorbidities [captured by the Charlson Comorbidity Index (CCI)] (p < 0.001), and depression (p = 0.012) were significantly associated with reported delirium symptoms.

Conclusion

Especially prior to elective surgery or medical interventions, screening for impaired executive function and depression could be helpful to identify patients who are at risk to develop delirium symptoms.

Common diseases alter the physiological age-related blood microRNA profile

Aging is a key risk factor for chronic diseases of the elderly. MicroRNAs regulate post-transcriptional gene silencing through base-pair binding on their target mRNAs. We identified nonlinear changes in age-related microRNAs by analyzing whole blood from 1334 healthy individuals. We observed a larger influence of the age as compared to the sex and provide evidence for a shift to the 5' mature form of miRNAs in healthy aging. The addition of 3059 diseased patients uncovered pan-disease and disease-specific alterations in aging profiles. Disease biomarker sets for all diseases were different between young and old patients. Computational deconvolution of whole-blood miRNAs into blood cell types suggests that cell intrinsic gene expression changes may impart greater significance than cell abundance changes to the whole blood miRNA profile. Altogether, these data provide a foundation for understanding the relationship between healthy aging and disease, and for the development of age-specific disease biomarkers.

Insulin sensitivity predicts cognitive decline in individuals with prediabetes

INTRODUCTION

Epidemiological studies indicate an association between type 2 diabetes and cognitive dysfunction that appear to start already in the prediabetic state. Although cross-sectional studies have linked insulin resistance to impaired cognition, the potential predictive value of insulin resistance has not yet been sufficiently studied longitudinally without confounding by overt diabetes (and its pharmacological treatment).

RESEARCH DESIGN AND METHODS

We investigated longitudinal data from participants of the 'Tübinger Evaluation of Risk Factors for Early Detection of Neurodegeneration' Study. Subjects underwent a neurocognitive assessment battery (CERAD Plus battery; Consortium to Establish a Registry for Alzheimer's Disease) at baseline and followed every 2 years (median follow-up 4.0 Q1-3: 2.2-4.3 years). Subjects within a pre-diabetic glycated hemoglobin range of 5.6%-6.5% underwent 5-point 75 g oral glucose tolerance tests (OGTTs) with assessment of insulin sensitivity and insulin secretion (n=175). Subjects with newly diagnosed diabetes mellitus or with major depressivity (Beck Depression Inventory >20) were excluded (n=15). Data were analyzed by mixed models using sex, age and glycemic trait as fixed effects. Subject and time since first measurement were used as random effects.

RESULTS

Insulin sensitivity was positively associated with the CERAD sum score (higher is better) in a time-dependent manner (p=0.0057). This result is mainly driven by a steeper decrease in the memory domain associated with lower insulin sensitivity (p=0.029). The interaction between age and insulin sensitivity was independent of glycemia (p=0.02). There was also no association between insulin secretion and cognition.

CONCLUSIONS

Insulin resistance rather than sole elevation of blood glucose predicts cognitive decline, specifically in the memory domain, in persons with prediabetes. Treatments of diabetes that improve insulin sensitivity might therefore have the potential to postpone or even prevent cognitive decline in patients with diabetes.

"I Trust in Staff's Creativity"-The Impact of COVID-19 Lockdowns on Physical Activity Promotion in Nursing Homes Through the Lenses of Organizational Sociology

Objectives: The health-enhancing benefits or regular physical activity (PA) reach into old age. With the emergence of the coronavirus disease of 2019 (COVID-19) pandemic and the associated national lockdowns and restrictions, nursing home residents were restrained from being physically active. In our study, we aimed to assess the impact of the COVID-19-related restrictions on PA promotion in nursing homes from an organizational-sociological lens. Methods: We collected data in eight nursing homes in Germany. Data collection included (i) semistructured interviews focusing on COVID-19-related restrictions and their effects on nursing homes from the home administrators' perspectives; (ii) open-ended surveys with nursing home staff and relatives focusing on daily routines and contact restrictions; and (iii) collection of documents such as care concepts, mission statements, and weekly activity plans. We analyzed all data with a reflexive thematic analysis approach. Results: We identified three stages of COVID-19-related changes in nursing homes that impacted PA promotion, as follows: (1) external closure and search for emergency control, (2) organizational adaptations to create a livable daily life in the internal environment, and (3) slow reintegration of interactions with the external organizational environment. Document analysis revealed that PA promotion was not part of decision programs or internal staff work descriptions. Rather, PA promotion was delegated to external service providers. The assignment of PA promotion to external providers was not structurally anchored in decision programs, which makes PA promotion not sustainable, particularly during unforeseen events that limit access to the organization. During the pandemic, executive staff believed in internal staff to buffer competencies with regard to PA promotion. Thus, executive staff often considered PA promotion relevant, even during the pandemic, but thought that PA promotion is a task that can be fulfilled by unqualified but motivated internal staff. Conclusion: While our study participants showed a high level of coping-capacity belief, it remains unclear which long-term impacts of COVID-19 on PA promotion in nursing homes are to be expected. At the practice level, executive staff in nursing homes that aim to promote PA within their organization should become aware that PA promotion needs to be incorporated into organizational structures to be implemented and continued in challenging times such as in a pandemic.

The effect of age and gender on anti-saccade performance: Results from a large cohort of healthy aging individuals

By 2050, the global population of people aged 65 years or older will triple. While this is accompanied with an increasing burden of age-associated diseases, it also emphasizes the need to understand the effects of healthy aging on cognitive processes. One such effect is a general slowing of processing speed, which is well documented in many domains. The execution of anti-saccades depends on a well-established brain-wide network ranging from various cortical areas and basal ganglia through the superior colliculus down to the brainstem saccade generators. To clarify the consequences of healthy aging as well as gender on the execution of reflexive and voluntary saccades, we measured a large sample of healthy, non-demented individuals (n = 731, aged 51-84 years) in the anti-saccade task. Age affected various aspects of saccade performance: The number of valid trials decreased with age. Error rate, saccadic reaction times (SRTs), and variability in saccade accuracy increased with age, whereas anti-saccade costs, accuracy, and peak velocity of anti-saccades and direction errors were not affected by age. Gender affected SRTs independent of age and saccade type with male participants having overall shorter SRTs. Our rigid and solid statistical testing using linear mixed-effect models provide evidence for a uniform slowing of processing speed independent of the actually performed eye movement. Our data do not support the assumption of a specific deterioration of frontal lobe functions with aging.

Gut Microbiome Signatures of Risk and Prodromal Markers of Parkinson Disease

OBJECTIVE

Alterations of the gut microbiome in Parkinson disease (PD) have been repeatedly demonstrated. However, little is known about whether such alterations precede disease onset and how they relate to risk and prodromal markers of PD. We investigated associations of these features with gut microbiome composition.

METHODS

Established risk and prodromal markers of PD as well as factors related to diet/lifestyle, bowel function, and medication were studied in relation to bacterial α-/β-diversity, enterotypes, and differential abundance in stool samples of 666 elderly TREND (Tübingen Evaluation of Risk Factors for Early Detection of Neurodegeneration) study participants.

RESULTS

Among risk and prodromal markers, physical activity, occupational solvent exposure, and constipation showed associations with α-diversity. Physical activity, sex, constipation, possible rapid eye movement sleep behavior disorder (RBD), and smoking were associated with β-diversity. Subthreshold parkinsonism and physical activity showed an interaction effect. Among other factors, age and urate-lowering medication were associated with α- and β-diversity. Physical inactivity and constipation were highest in individuals with the Firmicutes-enriched enterotype. Constipation was lowest and subthreshold parkinsonism least frequent in individuals with the Prevotella-enriched enterotype. Differentially abundant taxa were linked to constipation, physical activity, possible RBD, smoking, and subthreshold parkinsonism. Substantia nigra hyperechogenicity, olfactory loss, depression, orthostatic hypotension, urinary/erectile dysfunction, PD family history, and the prodromal PD probability showed no significant microbiome associations.

INTERPRETATION

Several risk and prodromal markers of PD are associated with gut microbiome composition. However, the impact of the gut microbiome on PD risk and potential microbiome-dependent subtypes in the prodrome of PD need further investigation based on prospective clinical and (multi)omics data in incident PD cases. ANN NEUROL 2020;88:320-331.

Diverging Awareness of Postoperative Delirium and Cognitive Dysfunction in German Health Care Providers

Purpose

Postoperative cognitive dysfunction (POCD) appears in up to 30% of patients suffering from postoperative delirium (POD). Both are associated with higher mortality and postoperative complications, prolonged hospital stays, and increased costs. Multi-modal models with pre-admission risk reduction counselling, perioperative monitoring, and training of multidisciplinary patient care providers have been shown to decrease the prevalence of both. The aim of our study is to understand how far those measures are known and implemented in routine care and to detect potential gaps in the current practice regarding risk communication and information flow between involved caregivers for patients at risk for POD/POCD.

Patients and Methods

As part of a multicenter study, seven semi-structured focus group (FG) discussions with nurses and physicians from tertiary care hospitals (surgery, anesthesiology, and orthopedics, n=31) and general practitioners (GPs) in private practice (n=7) were performed. Transcribed discussions were analyzed using qualitative content analysis.

Results

POD is present above all in the daily work of nurses, whereas physicians do not perceive it as a relevant problem. Physicians report that no regular risk assessment or risk communication was performed prior to elective surgery. Information about POD often gets lost during hand-offs and is not regularly reported in discharge letters. Thus, persisting cognitive dysfunction is often missed. The importance of standardized documentation and continuous education concerning risks, screening, and treatment was emphasized. The often-suggested pre-OP medication adjustment was seen as less important; in contrast, avoiding withdrawal was regarded as far more important.

Conclusion

Altogether, it seems that standards and available best practice concepts are rarely implemented. In contrast to physicians, nurses are highly aware of delirium and ask for standardized procedures and more responsibility. Therefore, raising awareness regarding risks, screening tools, and effective preventive measures for POD/POCD seems an urgent goal. Nurses should have a central role in coordination and care of POD to prevent the risk for POCD.

Patient safety, cost-effectiveness, and quality of life: reduction of delirium risk and postoperative cognitive dysfunction after elective procedures in older adults-study protocol for a stepped-wedge cluster randomized trial (PAWEL Study)

Background

Postoperative delirium is a common disorder in older adults that is associated with higher morbidity and mortality, prolonged cognitive impairment, development of dementia, higher institutionalization rates, and rising healthcare costs. The probability of delirium after surgery increases with patients’ age, with pre-existing cognitive impairment, and with comorbidities, and its diagnosis and treatment is dependent on the knowledge of diagnostic criteria, risk factors, and treatment options of the medical staff. In this study, we will investigate whether a cross-sectoral and multimodal intervention for preventing delirium can reduce the prevalence of delirium and postoperative cognitive decline (POCD) in patients older than 70 years undergoing elective surgery. Additionally, we will analyze whether the intervention is cost-effective.

Methods

The study will be conducted at five medical centers (with two or three surgical departments each) in the southwest of Germany. The study employs a stepped-wedge design with cluster randomization of the medical centers. Measurements are performed at six consecutive points: preadmission, preoperative, and postoperative with daily delirium screening up to day 7 and POCD evaluations at 2, 6, and 12 months after surgery. Recruitment goals are to enroll 1500 patients older than 70 years undergoing elective operative procedures (cardiac, thoracic, vascular, proximal big joints and spine, genitourinary, gastrointestinal, and general elective surgery procedures).

Discussion

Results of the trial should form the basis of future standards for preventing delirium and POCD in surgical wards. Key aims are the improvement of patient safety and quality of life, as well as the reduction of the long-term risk of conversion to dementia. Furthermore, from an economic perspective, we expect benefits and decreased costs for hospitals, patients, and healthcare insurances.

Trial registration

German Clinical Trials Register, DRKS00013311. Registered on 10 November 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3148-8) contains supplementary material, which is available to authorized users.

Cholinergic Pathway SNPs and Postural Control in 477 Older Adults

Objective: To determine whether single nucleotide polymorphisms (SNPs) of the cholinergic system and quantitative parameters of postural control are associated in healthy older adults. This is a cross-sectional analysis from the TREND study.

Methods: All participants performed a static postural control task for 30 s on a foam pad in semitandem stance and eyes closed. We analyzed mean power frequency (MPF), area, acceleration, jerk, and velocity from a mobile sensor worn at the lower back using a validated algorithm. Genotypes of four SNPs in genes involved in the cholinergic system (SLC5A7, CHAT, BCHE, CHRNA4) were extracted from the NeuroX chip. All participants present a normal neurological examination and a Minimental state examination score >24.

Results: Four hundred and seventy seven participants were included. Mean age was 69 years, 41% were female. One SNP of the cholinergic pathway was significantly associated with a quantitative postural control parameter. The minor allele of rs6542746 in SLC5A7 was associated with lower MPF (4.04 vs. 4.22 Hz; p = 3.91 × 10^-4). Moreover, the following associations showed trends toward significance: minor allele of rs6542746 in SLC5A7 with higher anteroposterior acceleration (318 vs. 287 mG; p = 0.005), and minor allele of rs3810950 in CHAT with higher mediolateral acceleration [1.77 vs. 1.65 log(mG); p = 0.03] and velocity [1.83 vs. 1.74 log(mm/s); p = 0.019]. Intraindividual occurrence of rs6542746 and rs3810950 minor alleles was dose-dependently related with lower MPF (p = 0.004).

Conclusion: This observational study suggests an influence of SNPs of the cholinergic pathway on postural control in older adults.

Effect of physical activity on cognitive flexibility, depression and RBD in healthy elderly

OBJECTIVE

The prevalence of Alzheimer's disease and Parkinson's disease increases with the raising number of elderly, which will be a challenging situation for the healthcare systems and society in the future. There is evidence that there are modifiable risk-factors e.g. physical activity for these diseases. Here, we study the interaction between sports inactivity with prodromal markers for neurodegeneration.

PATIENTS AND METHODS

We investigated 667 neurologically healthy individuals cross-sectional and a subgroup longitudinal over six years. Participants were stratified by their weekly sports activity. Prodromal markers (depression and REM sleep behaviour disorder (RBD)) as well as single and dual-tasking parameters and cognitive parameters were compared between the groups.

RESULTS

At baseline, sports activity was associated with lower BDI scores, lower occurrence of depressive syndrome and RBD, compared to sports inactivity. Further, active participants were faster in cognitive tasks associated with working memory and attention (Trail Making test part-A; TMT-B, ΔTMT-B-A) and better in gait and cognition parameters (single tasks and dual tasks) but not with overall cognition as measured with the MMSE. The association between physical inactivity and depression as well as TMT was present after six years.

CONCLUSION

We found that sports activity has a positive effect on cognitive flexibility, depressive symptoms and sleep which are all signs for a possible ongoing neurodegenerative process. Therefore, our results strengthen the potential role of sports activity as a positive disease modifier.

Gait Is Associated with Cognitive Flexibility: A Dual-Tasking Study in Healthy Older People

Objectives: To analyze which gait parameters are primarily influenced by cognitive flexibility, and whether such an effect depends on the walking condition used.

Design: Cross-sectional analysis.

Setting: Tübingen evaluation of Risk factors for Early detection of Neurodegenerative Disorders.

Participants: A total of 661 non-demented individuals (49–80 years).

Measurements: A gait assessment with four conditions was performed: a 20 m walk at convenient speed (C), at fast speed (F), at fast speed while checking boxes (FB), and while subtracting serial 7s (FS). Seven gait parameters from a wearable sensor-unit (McRoberts, Netherlands) were compared with delta Trail-Making-Test (dTMT) values, which is a measure of cognitive flexibility. Walking strategies of good and poor dTMT performers were compared by evaluating the patterns of gait parameters across conditions.

Results: Five parameters correlated significantly with the dTMT in the FS condition, two parameters in the F and FB condition, and none in the C condition. Overall correlations were relatively weak. Gait speed was the gait parameter that most strongly correlated with the dTMT (r² = 7.4%). In good, but not poor, dTMT performers differences between FB and FS were significantly different in variability-associated gait parameters.

Conclusion: Older individuals need cognitive flexibility to perform difficult walking conditions. This association is best seen in gait speed. New and particularly relevant for recognition and training of deficits is that older individuals with poor cognitive flexibility have obviously fewer resources to adapt to challenging walking conditions. Our findings partially explain gait deficits in older adults with poor cognitive flexibility.

Evidence for a Selectively Regulated Prioritization Shift Depending on Walking Situations in Older Adults

Background: Older adults have increased risks of balance issues and falls when walking and performing turns in daily situations. Changes of prioritization during different walking situations associated with dual tasking may contribute to these deficits. The objective of this study was therefore to investigate whether older adults demonstrate changes of prioritization during different walking paths.

Methods: In total, 1,054 subjects with an age range from 50 to 83 years were selected from the first follow-up visit of the TREND (Tuebinger evaluation of Risk factors for Early detection of Neurodegenerative Disorders) study. They were classified according to their performance on the Trail Making Test (TMT) into good and poor TMT performers (based on recent results showing that cognitive flexibility affects prioritization strategies during straight walking). Absolute dual-task performance and relative dual-task costs (DTC, relative performance under dual-task conditions compared with single-task conditions) were assessed in two paradigms: walking while subtracting serial 7 s and walking while checking boxes on a clipboard. Both tasks were performed on straight and curved paths.

Results: Overall, the poor TMT performers group performed worse in all single and dual tasks. Interestingly, the relative change in performance measured by dual-task costs differed in the groups between the two walking paths. On straight paths, poor TMT performers had a similar DTC of walking to that of good performers (p = 0.10) but had a significantly lower DTC of subtracting (p = 0.02). On curved paths, poor performers had a similar DTC of subtracting (p = 0.10), but their DTC of walking was significantly higher (p < 0.0001).

Conclusion: Given that walking on curved paths is considered more difficult than that on straight paths and that the serial subtracting dual task is more difficult than the box checking dual task, this study in older adults provides evidence for the existence of a (walking) situation-dependent change of prioritization. If confirmed in other studies, situation-dependent change of prioritization should be included as a potential factor contributing to gait and balance impairments, and increased fall risk in older adults.

Structured relearning of activities of daily living in dementia: the randomized controlled REDALI-DEM trial on errorless learning

Background

Errorless learning (EL) is a method for optimizing learning, which uses feed-forward instructions in order to prevent people from making mistakes during the learning process. The majority of previous studies on EL taught patients with dementia artificial tasks of little or no relevance for their daily lives. Furthermore, only a few controlled studies on EL have so far been performed and just a handful of studies have examined the long-term effects of EL. Tasks were not always trained in the patients’ natural or home environment, limiting the external validity of these studies. This multicenter parallel randomized controlled trial examines the effects of EL compared with trial and error learning (TEL) on the performance of activities of daily living in persons with Alzheimer’s or mixed-type dementia living at home.

Methods

Patients received nine 1-hour task training sessions over eight weeks using EL or TEL. Task performance was measured using video observations at week 16. Secondary outcome measures were task performance measured at week 26, satisfaction with treatment, need for assistance, challenging behavior, adverse events, resource utilization and treatment costs.

Results

A total of 161 participants were randomized, of whom 71 completed the EL and 74 the TEL arm at week 11. Sixty-nine EL patients and 71 TEL patients were assessed at the 16-week follow-up (the primary measurement endpoint). Intention-to-treat analysis showed a significantly improved task performance in both groups. No significant differences between the treatment groups were found for primary or secondary outcomes.

Conclusions

Structured relearning improved the performance of activities of daily living. Improvements were maintained for 6 months. EL had no additional effect over TEL.

Trial registration

German Register of Clinical Trials DRKS00003117. Registered 31 May 2011.

Electronic supplementary material

The online version of this article (doi:10.1186/s13195-017-0247-9) contains supplementary material, which is available to authorized users.

Associations between Early Markers of Parkinson's Disease and Sarcopenia

Introduction: Sarcopenia and Parkinson's disease (PD) are both common age-related syndromes, and there is preliminary evidence that the probability of the co-occurrence of these syndromes within one individual is higher than expected. However, it is unclear to date whether one of the syndromes induces the other, or whether there may be common underlying causes. This pilot study thus aimed at investigating the association of the features of increased risk for PD with early stage sarcopenia (ESS). Method: Two hundred and fifty-five community-dwelling individuals were recruited from the Tübinger evaluation of Risk factors for Early detection of NeuroDegeneration (TREND) study. The following features that are associated with an increased risk for future PD were evaluated: the motor part of the Unified PD Rating Scale (UPDRS-III), hyperechogenicity of the substantia nigra, prevalence of lifetime depression, hyposmia, REM sleep behavior disorder and the recently introduced probability score for prodromal PD. Sarcopenia was defined according to the European Working Group on Sarcopenia in Older People, which was adapted to this cohort of healthy adults. Multiple linear regression analysis was used to identify associations of PD-related features with ESS. Results: The UPDRS-III score was significantly associated with ESS. The result remained significant after the adjustment for age, gender and physical activity. No association was found between the other PD-related features and ESS. Conclusion: The significant association of the UPDRS-III score with ESS in this cohort might indicate a common and early pathway in both diseases and supports the existence of an "extended neurodegenerative overlap syndrome." Moreover, the potential of EES to serve as a prodromal marker of PD should be evaluated in future studies.

Association of Plasma Aβ40 Peptides, But Not Aβ42, with Coronary Artery Disease and Diabetes Mellitus

BACKGROUND/OBJECTIVE

Plasma levels of amyloid-beta (Aβ) 1-40 peptide have been proposed to be associated with cardiovascular mortality in patients with coronary artery disease (CAD). Therefore, we aimed to investigate the association of plasma Aβ levels with CAD, cardiovascular risk factors (CVRF), and APOE genotype in non-demented elderly individuals.

METHODS

Plasma Aβ1 - 40 and Aβ1 - 42 levels of 526 individuals (mean age of 63.0±7.3 years) were quantified with the INNO-BIA plasma Aβ forms assay based on multiplextrademark technique. APOE genotype was determined with an established protocol. Presence of CAD and CVRFs were ascertained using a questionnaire and/or medical records.

RESULTS

Plasma Aβ1 - 40 levels were significantly higher in individuals with CAD (p = 0.043) and, independently, in individuals with diabetes mellitus (DM) type 2 (p = 0.001) while accounting for age- and gender-effects. Plasma Aβ1 - 42 levels were higher in APOEɛ4 carriers (p = 0.004), but were neither relevantly associated with CAD nor with any CVRF. Plasma Aβ1 - 40 showed no association with APOE genotype.

DISCUSSION

Our findings argue for an association of circulating plasma Aβ1 - 40 peptides with incident CAD and DM. Further investigations are needed to entangle the role of Aβ1 - 40 role in the pathophysiology of cardiovascular disease independent of its known role in Alzheimer's disease.

Cognitive Performance Patterns in Healthy Individuals with Substantia Nigra Hyperechogenicity and Early Parkinson's Disease

Introduction: Hyperechogenicity of the substantia nigra (SN+) is a risk marker for Parkinson’s disease (PD) which can be detected before the diagnosis. In healthy individuals, SN+ has been associated with slight deficits in specific cognitive functions, suggesting cognitive impairment as a possible pre-diagnostic marker for PD. However, the pattern of cognitive deficits associated with SN+ has not yet been compared with those present in PD.

Methods: Data of 262 healthy individuals with normal echogenicity (SN-) and 48 healthy individuals with SN+ were compared with 82 early stage PD patients using the “Consortium to Establish a Registry for Alzheimer’s disease” test battery. First, the test clusters (factors) were identified using a principal component analysis (PCA). Mean group performance of cognitive tests belonging to distinct factors, according to the PCA, and single subtest performances were compared using analyses of variance. Second, the number of individuals with abnormal cognitive performances (z-score < -1.0) were compared between groups.

Results: Verbal memory, semantic and executive function, and praxis were identified as components of cognitive performances. The SN+ group performed significantly worse than the SN- group in tests assessing semantic and executive function, with a non-significant decrease in verbal memory. On the subtest level, individuals of the SN+ group scored significantly lower than the SN- group on the Boston Naming Test (BNT; p = 0.008). In all subtests, the percentages of PD patients with values below the cut-off for abnormal performance were higher than in the SN- group. Moreover, more individuals from the SN+ group scored below the cut-off in the BNT (SN- = 8.4%, SN+ = 20.8%, p = 0.01) and TMT-B (SN- = 6.9%, SN+ = 16.7%, p = 0.02), compared to the SN- group.

Conclusion: This study confirms poorer performance of healthy individuals with SN+ compared to SN- in specific cognitive domains. However, against the SN- group, the cognitive profile of the SN+ group was not fully consistent with the profile of early PD patients. Our data argues that cognitive impairment associated with SN+ might differ slightly from that seen in early PD. Compensational mechanisms in the early phases of neurodegeneration, and the fact that only a subgroup of SN+ will develop PD, may partly explain these differences.

Dual Tasking for the Differentiation between Depression and Mild Cognitive Impairment

Differentiation of mild cognitive impairment from depression in elderly adults is a clinically relevant issue which is not sufficiently solved. Gait and dual task (DT) parameters may have the potential to complement current diagnostic work-up, as both dementia and depression are associated with changes of gait and DT parameters.

METHODS

Seven hundred and four participants of the TREND study (Tübinger evaluation of Risk factors for Early detection of NeuroDegeneration) aged 50-80 years were assessed using the Consortium to Establish a Registry for Alzheimer's Disease Plus test battery for testing cognition and Beck's Depression Inventory for evaluation of depression. Based on these results, four groups were defined: acute depressed (N = 53), cognitively mildly impaired (N = 97), acute depressed, and cognitively mildly impaired (N = 15), and controls (N = 536). Participants underwent a 20 m walk and checking boxes task under single (ST) and DT conditions. ST and DT performance and dual task costs (DTC) were calculated. Due to the typical age of increasing incidence of depressive and also cognitive symptoms, the 7th decade was calculated separately.

RESULTS

ST speeds of gait and checking boxes, DT walking speed, and walking DTC were significantly different between groups. Healthy controls were the fastest in all paradigms and cognitively mildly impaired had higher DTC than depressed individuals. Additionally, we constructed a multivariate predictive model differentiating the groups on a single-subject level.

CONCLUSION

DT parameters are simply and comfortably measureable, and DTC can easily be determined. The combination of these parameters allows a differentiation of depressed and cognitively mildly impaired elderly adults.

Prospective longitudinal course of cognition in older subjects with mild parkinsonian signs

Background

Mild parkinsonian signs (MPS) are common in older people and are associated with an increased risk of different neurodegenerative diseases. This study prospectively evaluates the longitudinal course of cognitive performance in older individuals with MPS.

Methods

From the TREND study, 480 individuals neurologically healthy at baseline, aged between 50 and 80 years, with complete follow-up data for three assessments within a mean of 43.8 months, were included in this analysis. Participants underwent a detailed cognitive test battery, evaluation of prodromal markers for neurodegenerative diseases and history of vascular diseases at each study visit. In addition, plasma levels of amyloid-beta (Aβ)_1–40 and Aβ_1–42 were evaluated longitudinally.

Results

In 52 (11 %) of the 480 participants, MPS could be detected at baseline. These individuals had cognitive deficits significantly more often compared with controls at each time point and their cognitive performance showed a steeper decline during follow-up. In addition, their levels of plasma Aβ_1–42 were significantly lower than those of controls, and declined more rapidly over time.

Conclusions

This longitudinal study shows that MPS are associated with cognitive decline and decrease in plasma Aβ_1–42, possibly indicating an ongoing neurodegenerative process.

Electronic supplementary material

The online version of this article (doi:10.1186/s13195-016-0209-7) contains supplementary material, which is available to authorized users.

[Implementation of auricular acupuncture by the NADA protocol in geriatric patients suffering from major depression : A mixed methods feasibility study]

BACKGROUND

The number of elderly patients with depression has steadily increased in recent years; therefore, new treatment options and therapy approaches are urgently needed to improve treatment in this patient group. The aim of this project was to evaluate the additional application of auricular acupuncture according to the NADA protocol in patients treated in a daytime ward in terms of acceptability and feasibility.

METHODS

A total of 20 psychogeriatric patients from a daytime clinic suffering from major depression (ICD-10: F32-F33) received auricular acupuncture in addition to the standard treatment three times per week over a treatment course of 3 weeks. Semi-structured interviews were conducted with the participants and the therapeutic team and qualitative content analyses were carried out. Depression, cognition, quality of sleep and quality of life were assessed using validated quantitative instruments.

RESULTS

There was a 95 % utilization of the therapy. The qualitative analysis showed a high acceptance by all participants. The dominant perception by the patients was a positive expectation and conviction that acupuncture was an effective form of therapy without side effects, which could contribute to recovery. The majority of patients also felt that there was an improvement in the symptoms. The quantitative analysis revealed significant improvements in the target parameters.

CONCLUSION

The acceptance of the intervention by the patients and the willingness of the interdisciplinary team underlines the feasibility of this implementation within a fixed therapeutic concept. The significant pre-post improvements indicated a potential benefit and should be verified in further efficacy studies.

Age and Vascular Burden Determinants of Cortical Hemodynamics Underlying Verbal Fluency

BACKGROUND

Aging processes and several vascular burden factors have been shown to increase the risk of dementia including Alzheimer's disease. While pathological alterations in dementia precede diagnosis by many years, reorganization of brain processing might temporarily delay cognitive decline. We hypothesized that in healthy elderly individuals both age-related neural and vascular factors known to be related to the development of dementia impact functional cortical hemodynamics during increased cognitive demands.

METHODS

Vascular burden factors and cortical functional hemodynamics during verbal fluency were assessed in 1052 non-demented elderly individuals (51 to 83 years; cross-sectional data of the longitudinal TREND study) using functional near-infrared spectroscopy (fNIRS). The prediction of functional hemodynamic responses by age in multiple regressions and the impact of single and cumulative vascular burden factors including hypertension, diabetes, obesity, smoking and atherosclerosis were investigated.

RESULTS

Replicating and extending previous findings we could show that increasing age predicted functional hemodynamics to be increased in right prefrontal and bilateral parietal cortex, and decreased in bilateral inferior frontal junction during phonological fluency. Cumulative vascular burden factors, with hypertension in particular, decreased left inferior frontal junction hemodynamic responses during phonological fluency. However, age and vascular burden factors showed no statistical interaction on functional hemodynamics.

CONCLUSION

Based on these findings, one might hypothesize that increased fronto-parietal processing may represent age-related compensatory reorganization during increased cognitive demands. Vascular burden factors, such as hypertension, may contribute to regional cerebral hypoperfusion. These neural and vascular hemodynamic determinants should be investigated longitudinally and combined with other markers to advance the prediction of future cognitive decline and dementia.

Reasons for mild parkinsonian signs - which constellation may indicate neurodegeneration?

INTRODUCTION

Mild parkinsonian signs (MPS) are common in the elderly population. Several factors including physical decline and comorbidities in addition to neurodegeneration may be possible sources for MPS. The objective was to examine whether MPS are associated with a history of orthopedic disturbances, vascular diseases or prodromal markers for neurodegeneration.

METHODS

The TREND study is a prospective longitudinal cohort study in individuals >50 years with biennial assessments designed to identify prodromal markers for neurodegeneration. In this substudy, 1091 elderly individuals were evaluated for a possible association of MPS with prodromal markers for neurodegeneration, orthopedic disturbances, vascular diseases, as well as cerebral abnormalities. These factors were assessed by self-administered questionnaires, with a structured health interview, a neurological examination and by transcranial sonography.

RESULTS

82 participants showed MPS. They were found to have more often hyposmia and RBD, had a higher autonomic dysfunction score and they more frequently showed hyperechogenicity of the substantia nigra compared to controls. Neither orthopedic disturbances nor vascular diseases were significantly associated with the prevalence of MPS.

CONCLUSION

MPS might be a sign of early neurodegeneration rather than caused by other motor influencing diseases.

A neurodegenerative vascular burden index and the impact on cognition

A wide range of vascular burden factors has been identified to impact vascular function and structure as indicated by carotid intima–media thickness (IMT). On the basis of their impact on IMT, vascular factors may be selected and clustered in a vascular burden index (VBI). Since many vascular factors increase the risk of Alzheimer’s disease (AD), a multifactorial neurodegenerative VBI may be related to early pathological processes in AD and cognitive decline in its preclinical stages. We investigated an elderly cohort at risk for neurodegeneration (TREND study, n = 1102) for the multifactorial influence of vascular burden factors on IMT measured by ultrasound. To create a VBI for this cohort, vascular factors and their definitions (considering medical history, medication, and/or blood marker data) were selected based on their statistical effects on IMT in multiple regressions including age and sex. The impact of the VBI on cognitive performance was assessed using the Trail-Making Test (TMT) and the consortium to establish a registry for Alzheimer’s disease (CERAD) neuropsychological battery. IMT was significantly predicted by age (standardized β = 0.26), sex (0.09; males > females) and the factors included in the VBI: obesity (0.18), hypertension (0.14), smoking (0.08), diabetes (0.07), and atherosclerosis (0.05), whereas other cardiovascular diseases or hypercholesterolemia were not significant. Individuals with 2 or more VBI factors compared to individuals without had an odds ratio of 3.17 regarding overly increased IMT ( ≥ 1.0 mm). The VBI showed an impact on executive control [log(TMT B−A), p = 0.047] and a trend toward decreased global cognitive function (CERAD total score, p = 0.057) independent of age, sex, and education. A VBI established on the basis of IMT may help to identify individuals with overly increased vascular burden linked to decreased cognitive function indicating neurodegenerative processes. The longitudinal study of this risk cohort will reveal the value of the VBI as prodromal marker for cognitive decline and AD.

Prodromal features for Parkinson's disease--baseline data from the TREND study

BACKGROUND AND PURPOSE

A number of non-motor features are known to precede motor manifestations of Parkinson's disease (PD). They are supposed to already represent the prodromal neurodegenerative state in those who later develop PD and are thus called prodromal markers. In this study, three prodromal markers, depression, rapid eye movement behaviour disorder (RBD) and hyposmia, were selected and were related to other prodromal features in elderly individuals without PD.

METHODS

From the Tübinger Evaluation of Risk Factors for Early Detection of Neurodegeneration (TREND) study, 698 healthy individuals aged 50-80 years reporting one or more of the selected prodromal markers (SPMs), but without neurodegenerative disorders, were evaluated and classified according to the status of prodromal markers. Other prodromal PD-related features were assessed with a 23-item questionnaire and compared between participants with and without the three SPMs.

RESULTS

Individuals with the SPMs for PD endorsed more of the additional possible prodromal features of PD than those without; of 23 possible prodromal features, the median number identified amongst participants with no SPMs was two, compared with four with one marker, five with two and seven with three (P < 0.001). Regarding individual SPMs, participants with depression and RBD endorsed five of 23 markers, compared with three for those with hyposmia (P = 0.001). There was no significant increase in the number of prodromal features amongst those with two SPMs compared with those with only one marker.

CONCLUSIONS

Individuals with the SPMs for PD report a higher prevalence of other prodromal PD symptoms. This may indicate that these markers can identify individuals at risk for PD.

Lowered serum amyloid-β1-42 autoantibodies in individuals with lifetime depression

Reduced levels of naturally occurring autoantibodies against amyloid-β (Aβ) have been described in Alzheimer's disease (AD). Lifetime depression doubles the risk of AD, thus these autoantibodies may also be reduced in this group. We measured serum IgG autoantibody titers against Aβ1-42, S100b and α-synuclein in 214 individuals with depression and 419 controls. Titers against Aβ1-42 were lower in individuals with lifetime depression (5544.6 ± 389.3) compared to controls (7208.7 ± 482.4; p = 0.048). Titers against S100b and α-synuclein were comparable between the cohorts. These data suggest an AD-like impairment of the humoral immune response in a relevant proportion of individuals with depression.