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OBJECTIVE: To investigate prospectively the prognostic power of various demographic and diagnostic parameters, as well as of medical history, for evaluating in elderly patients the probability of their requiring care and of their risk of dying soon. PATIENTS AND METHOD: All the elderly patients (> or = 70 years) of one general practitioner were included. Of 178 patients who fulfilled the inclusion criteria, 144 participated (93 women, 49 men; mean age 78.7 +/- 5.8 years). Demographic, basic diagnostic and medical history data of the kind that can be easily collected in general practice were recorded. The general practitioner was also asked to assess the probability of each patient requiring care and the likelihood of their dying soon. Several functional tests that record or measure daily activity were conducted. After 18 months all admissions to care, homes for the elderly or hospital and deaths were recorded. The different groups were compared. RESULTS: The probability of requiring care and of dying within the observation period were predicted more accurately by functional tests and questions than by conventional diagnostic methods. This was particularly so for functional investigations of basic daily activity, cognitive ability and manual skills. There were significant differences between the groups in the results of tests (P < 0.01). CONCLUSION: Functional tests can be rapidly performed and have high diagnostic and prognostic power. They are therefore recommended for use by general practitioners for assessing the probability of a given patient requiring care and for estimating the likelihood of early death.

Among 196 patients with a mean age of 80 years there were, at the time of hospitalization, 12.2% who had been prescribed wrong or partly even high-risk medication drugs, some of which carried a high risk. Among 694 prescriptions 4.2% were faulty. The faults consisted of failure to take account of impaired renal function, contraindications, accompanying illnesses, and misinterpretation of side-effects. 80% of these prescriptions were for diuretics, psychoactive and antiarrhythmic drugs, digitalis and hypnotics. The number of faulty prescriptions on discharge was 1.4%. In all, the average number of prescribed drugs had decreased from 3.5 on admission to 2.9 on discharge. This retrospective study demonstrates that the manner of prescribing for elderly patients needs to be handled more critically and rationally.

The long-term effect of a low-fat diet and physical training was investigated in 36 men (mean age 51 +/- 6 years) with coronary heart disease (one-vessel disease, n = 11; two vessel-disease: n = 18; three-vessel disease: n = 7). 18 patients (interventionist, group 1) undertook physical training within a coronary sport group (1 h twice weekly) and daily bicycle ergometry (30 min). They were held to a low-fat diet. In the remaining 18 patients (control, group 2), physical training and low-fat diet depended on own initiative after receiving advice. Over an observation period of 6 years total cholesterol concentration in the 17 patients of group 1 decreased significantly (243 +/- 33 vs. 219 +/- 28 mg/dl; P < 0.02). Physical performance in 12 patients (group 1) increased from 169 +/- 40 to 202 +/- 42 W in (P < 0.01). In contrast, total cholesterol increased slightly in group 2 (n = 16) from 245 +/- 31 at the beginning to 247 +/- 39 mg/dl (no significant change) at the end of the 6 years. Physical performance (n = 12) decreased slightly from 165 +/- 45 to 146 +/- 52 W (not significant). The difference between the two groups was significant after 6 years (P < 0.02 and P < 0.007, respectively). There seemed to be a tendency for progression of the coronary heart disease to be slower in the interventionist than the control group.

Falsely high serum triglyceride concentrations (410-850 mg/dl) were measured in four members of a family of five from Franconia in Germany. The cause was hyperglyceridaemia on the basis of glycerol kinase deficiency. None had any symptoms and no other metabolic anomaly was demonstrated. The possibility of glycerol kinase deficiency should be considered in any case of elevated serum triglyceride concentration but with clear serum, normal lipid electrophoresis and lack of response to lipid-lowering measures.

The causes of early rehospitalization (within 3 weeks) of very elderly patients, its possible avoidance and appropriate preventive measures were analysed retrospectively in patients of a geriatric hospital. Included were all those patients who had been admitted to the hospital from their home several (mean: five) times between 1987 and 1990 (48 women, 19 men; mean age 81.3 +/- 7.2 years--a total of 331 re-admissions). The most frequent diagnoses were heart failure (38.8%), acute cerebrovascular accident or its sequelae (31.3%), dementia (23.9%), fall or its sequelae (22.3%) and diabetes (20.9%). Of the 331 re-admissions 87 (26.3%) occurred during the first 3 weeks after discharge. The most important reasons of this early re-admissions were inadequate home care (41.4%), undesirable drug effects and non-compliance (25.3%), as well as rapid progression of the basic disease (14.9%). In the judgement of the hospital team more than 40% of the early re-admissions were avoidable, among those re-admitted because of inadequate home care and those in connection with drug intake even more than half. Early hospitalization is frequently avoidable, if individual geriatric assessment is undertaken and discharge carefully planned.

Twenty obese patients were either given a caloric restricted diet (300 kcal/d) over 4 weeks alone or underwent an additional ergometer exercise programme for up to 2 hours daily. Combination therapy resulted in an improvement of physical performance by 26% despite weight loss of 11 kg. Blood pressure could be reduced both at rest and on exercise. Blood pressure regulation and heart rate under orthostatic conditions remained unchanged for both therapeutical approaches. The effect on carbohydrate and lipid metabolism was also more favorable in patients on combination therapy than in those given a reduction diet alone. Combination of reduction diet and physical exercise is therefore superior to caloric restriction alone with regard to cardiovascular and metabolic considerations.

Ernahrungstherapie bei Mangelernahrung alter Menschen sollte nach Moglichkeit auf oralem Wege erfolgen. Sie stellt eine besondere Anforderung an Angehorige, Pflegende und Arzte dar. Aufgrund der individuellen Defizite mus fur jeden Patienten ein angepaster Therapieplan erstellt werden. Als Masnahmen stehen im engeren Sinne die Optimierung des Nahrungsangebotes, energiereiche und angereicherte Kost und flussige Nahrungssupplemente sowie im weiteren Sinn die Optimierung der Betreuung und des Umfeldes bei den Mahlzeiten zur Verfugung. Der Erfolg dieser Masnahmen hangt im wesentlichen von der Intensitat der jeweiligen Betreuung ab.

The prevalence of Gilbert's syndrome was studied in a randomized group of 1530 persons (785 men and 745 women, aged 20-40 years) living in the Heidelberg region of the Federal Republic of Germany. It was found to be present in 12.4% of men and 4.8% of women, i.e. a total of 8.6% for the entire group. In women the serum bilirubin level (mean 12.0 +/- 5.1 mumol/l) was significantly lower than in men (mean of 13.7 +/- 6.8 mumol/l; P less than 0.001). Analysing the frequency distribution of serum bilirubin revealed that patients with this syndrome do not constitute a population of its own, but rather form the upper end of the normative bilirubin distribution curve.

Im Rahmen der Sturzpravention wird u.a. eine routinemasige Uberprufung der Medikation gefordert. In einer Zufallsstichprobe von 276 uber 75jahrigen Krankenhauspatienten wurde untersucht, wie haufig Arzneimittel verordnet werden, die uber die mogliche Auslosung von Schwindel das Sturzrisiko erhohen konnen. Schwindelbeschwerden und Sturzereignisse wurden standardisiert erhoben. Patienten, die uber Schwindel klagten, gaben Sturze 10mal haufiger an als Patienten ohne Schwindel. Arzneimittel, die als mogliche Nebenwirkung Schwindel verursachen konnen, wurden sehr haufig verordnet. Neuroleptika, Antidepressiva und Hypnotika/Sedativa sowie Kombinationsverordnungen hypotensiv wirksamer Medikamente waren signifikant haufiger fur Patienten verordnet, die uber Schwindel klagten. Eine systematische Durchsicht der Medikation im Rahmen einer Sturzpravention erscheint sinnvoll, insbesondere bei Vorliegen von Mehrfachverordnungen.

The objective of this study, designed as a randomized controlled prospective intervention study, was to evaluate the effect of nutritional supplementation on functional status and need of care in undernourished geriatric patients during hospitalization, and up to 6 months after discharge. Participants consisted of 46 undernourished geriatric patients from a geriatric acute care hospital aged 75 years or older without malignant disease, or need for tube feeding or parenteral nutrition. Patients in the supplement group (SG, N = 20) were offered 400 mL (2100 kJ) daily of a liquid supplement during hospital stay and 200 mL (1050 kJ) per day for the following 6 months at home. Patients in the control group (CG, N = 26) had usual care without supplements. The main outcome measure was functional status based on the Barthel Activities of Daily Living score (ADL) at hospital admission, discharge and after 6 months, with higher scores indicating greater independence and a maximum score of 100 points. In supplemented patients with good acceptance (SG+, N = 11), a median improvement of 20 points was observed between admission and discharge, and a further improvement of 5 points at home. Median changes were 0 and -10 points in supplemented patients with poor acceptance (SG-, N = 9) and 5 and 2.5 points in CG, respectively. In SG+, the proportion of independent patients (> 65 points) increased continuously from 36% at admission to 63% at discharge, to 72% after 6 months, and was significantly higher compared to CG at discharge (63% vs 19%, p < 0.05) and after 6 months (72% vs 39%, p < 0.05). 64% of the patients in SG+ improved during hospitalization, compared to 23% in CG (p < 0.05). In the six months at home, 18% of SG+ improved; none of SG+ deteriorated in hospital or at home. In contrast, deterioration of the ADL score occurred in considerable proportions of SG- (22% in hospital, 22% at home) and CG (4% at hospital, 12% at home) patients. The proportion of patients who improved was smaller in SG- (44% at hospital, 22% at home) as well as in CG (23% at hospital, 35% at home), compared to SG+. In conclusion, a positive functional course was evident in supplemented patients with good acceptance during hospitalization, and further improvement was observed during the following 6 months at home. Nutritional support may contribute to reconvalescence and recovery of undernourished geriatric patients.

To determine predictors of death, nursing home placement and hospital admission, a prospective study was carried out in a university-affiliated geriatric hospital and a general practice. One hundred and thirty-five patients consecutively admitted from home to the geriatric hospital and discharged home again (site 1), and 144 patients, aged 70 years and over, of a general practice (site 2) were recruited for a comprehensive geriatric assessment program. At baseline, none was completely dependent on others, or severely demented. At follow-up after 18 months, 46 subjects (17%) had died, 20 subjects (7%) had been institutionalized, and 79 had been admitted to hospital (28 %) in the interim. Univariate analysis demonstrated a significant association between Barthel Activities of Daily Living (ADL), Lawton-Brody Instrumental Activities of Daily Living (IADL), Mini-Mental State Examination (MMSE), Balance and Gait Evaluation, Timed “Up and Go”, Timed Test of Money Counting, Grip-Strength and Williams Board Test, and death as well as nursing home placement. Barthel-ADL were significantly correlated with hospital admission. In a logistic regression analysis, Barthel-ADL were independent predictors for death; Barthel-ADL, Timed “Up and Go”, Timed Test of Money Counting, and Williams Board Test were independent predictors for nursing home placement. No independent predictor was found for hospital admission. It is concluded that self-report and performance-based measures of functional capabilities are useful instruments to identify patients at risk for nursing home placement and death. Factors contributing to hospital admissions are other than those measured by the applied tests.

In this study, 113 patients with modestly elevated levels of low-density lipoprotein cholesterol (210 mg/dl) and coronary artery disease were randomized to an intervention group (n=56) or a control group (n=57). The intervention program consisted of daily exercise and a low-fat diet according to the American Heart Association's recommendation phase III; patients in the control group received "usual care" rendered by their private physician. After 1 year, complete data were available for all 92 patients (intervention: n=40; control: n=52) who underwent repeat coronary angiography. During the study course, patients in the intervention group showed an increase in apolipoprotein A-I(123 +/- 18 vs 129 +/- 20 mg/dl; p0.02) and apolipoprotein A-I/B (1.3 +/- 0.4 vs 1.5 +/- 0.4; p0.01) and a decrease in apolipoprotein B (99 +/- 20 vs 89 +/- 18 mg/dl; p0.01), while apolipoprotein A-II remained unchanged (38 +/- 6 vs 38 +/- 6 mg/dl; p=NS). In the control group, there were no significant changes (apolipoprotein A-I, 124 +/- 17 vs 128 +/- 13 mg/dl; apolipoprotein A-II, 38 +/- 6 vs 39 +/- 6 mg/dl; apolipoprotein B, 100 +/- 21 vs 99 +/- 16 mg/dl; apolipoprotein A-I/B, 1.3 +/- 0.3 vs 1.4 +/- 0.5; all p=NS). As previously reported, there was a significant retardation of progression in patients in the intervention group (progression 23%, no change 45%, regression 32%) compared with the control group (progression 48%, no change 35%, regression 17%) (p0.05). Although retardation of progression was significantly associated with an increase in apolipoprotein A-I/B and a decrease in apolipoprotein B (p0.05), these gave way in multivariate analysis to changes in total cholesterol/high-density lipoprotein cholesterol, absolute levels of low-density lipoprotein cholesterol, and, in a subgroup of patients, to leisure-time physical activity (all p0.05). These data demonstrate that an intervention based on a low-fat diet and intensive physical exercise is capable of improving apolipoprotein levels, associated with retardation of progression of coronary artery disease. However, total cholesterol/high-density lipoprotein cholesterol and low-density lipoprotein cholesterol appear superior to apolipoproteins as metabolic markers for effective treatment in patients with coronary artery disease.

Objectives: To examine medication problems during a stay in hospital and after discharge and to identify risk factors that contribute to poor compliance with medication a prospective observational study was carried out in an university-affiliated geriatic hospital and a patients' home. Patients: One hundred and nineteen patients admitted from home to the geriatric hospital underwent a comprehensive geriatric assessment. They were also tested in opening and removing tablets from various common medicine containers. Drug prescriptions before, during and after the hospital stay were recorded. Medication use at home was observed by a member of a hospital-based home intervention team. The patients' reports of their drug therapy was compared with those by their family doctors. Results: Of all tested patients 10.1% failed to open at least one container. This inability was associated with poor vision, impaired cognitive function and low manual dexterity. Compliance with prescribed medication was associated with cognitive function, ability to handle medication containers, number of prescribed drugs and recent changes in drug prescriptions. Of the patients only 39.5% had stable drug prescriptions during the 3-month study period. Doctor/patient agreement concerning drug therapy was low in all age groups. The agreement rate and patients' knowledge of their treatment was correlated with cognitive function and the number of prescribed drugs. Conclusion: Patients' ability to open and remove tablets from common commercial packages/containers should be tested routinely during a stay in hospital. Management of medication should be taught and supervised within the first few days after discharge from hospital.

The objective of the study was to compare compliance with and the hypocholesterolaemic effect of lovastatin given once daily as a morning or an evening dose. Twenty-four out-patients with familial hypercholesterolaemia were randomly assigned to receive placebo first, then lovastatin 20 mg, to be taken once daily for 4 weeks, either with the breakfast or evening meal, in a single-blind fashion. Drug compliance was assessed by pill counts and continuous electronic monitoring. Two compliance parameters were evaluated, consumption, defined as percentage of prescribed doses taken, and time compliance, the percentage of total dosing events recorded within defined intervals (6.00-10.00 h, and 17.00-21.00 h), for the morning and evening regimes. Both regimes satisfactorily reduced the total and LDL-cholesterol concentrations, and there was no significant difference in the extent of the reductions. Pill counts overestimated compliance, as revealed by the monitoring method. The times of actual consumption of doses by the patients often differed from that prescribed, predominantly in patients who were told to take the evening dose. Partial time compliance may have confounded the efficacy of the drugs. Electronic compliance monitoring appears to be particularly useful in chronopharmacological studies.

BACKGROUND Significant regression of coronary and femoral atherosclerotic lesions has been documented by angiographic studies using aggressive lipid-lowering treatment. This study tested the applicability and effects of intensive physical exercise and low-fat diet on coronary morphology and myocardial perfusion in nonselected patients with stable angina pectoris. METHODS AND RESULTS Patients were recruited after routine coronary angiography for stable angina pectoris; they were randomized to an intervention group (n = 56) and a control group on "usual care" (n = 57). Treatment comprised intensive physical exercise in group training sessions (minimum, 2 hr/wk), daily home exercise periods (20 min/d), and low-fat, low-cholesterol diet (American Heart Association recommendation, phase 3). No lipid-lowering agents were prescribed. After 12 months of participation, repeat coronary angiography was performed; relative and minimal diameter reductions of coronary lesions were measured by digital image processing. Change in myocardial perfusion was assessed by 201Tl scintigraphy. In patients participating in the intervention group, body weight decreased by 5% (p less than 0.001), total cholesterol by 10% (p less than 0.001), and triglycerides by 24% (p less than 0.001); high density lipoproteins increased by 3% (p = NS). Physical work capacity improved by 23% (p less than 0.0001), and myocardial oxygen consumption, as estimated from maximal rate-pressure product, by 10% (p less than 0.05). Stress-induced myocardial ischemia decreased concurrently, indicating improvement of myocardial perfusion. Based on minimal lesion diameter, progression of coronary lesions was noted in nine patients (23%), no change in 18 patients (45%), and regression in 13 patients (32%). In the control group, metabolic and hemodynamic variables remained essentially unchanged, whereas progression of coronary lesions was noted in 25 patients (48%), no change in 18 patients (35%), and regression in nine patients (17%). These changes were significantly different from the intervention group (p less than 0.05). CONCLUSIONS In patients participating in regular physical exercise and low-fat diet, coronary artery disease progresses at a slower pace compared with a control group on usual care.

To obtain reference values for comparison with malnourished geriatric patients, the nutritional status of 50 apparently healthy women aged 75 or older living independently in two old people's homes in Heidelberg was examined. All women were able to walk, and were free from overt disease and signs of mental deterioration. Anthropometric measurements (body height and weight, triceps skinfold thickness, midarm circumference) and biochemical determinations of protein and vitamin status were performed. Anthropometric parameters were similar to those obtained in "younger" samples of healthy elderly, lower than those reported in younger adults, and markedly greater than those reported in geriatric patients. The majority of biochemical findings were within normal reference ranges established for healthy young adults. Only plasma retinol concentrations were below the reference limit in 8 women (16%). These findings show clearly that even in the very old, major alterations in biochemical indicators of nutritional status are rare. Neither advanced age nor institutionalization are associated with malnutrition. This obviously suggests that malnutrition in old age is mainly related to physical and mental disabilities.

A prospective drug surveillance study was undertaken in 300 elderly patients admitted to a geriatric clinic. Prescribing patterns were determined on admission, at discharge and 3.6 and 18 months after discharge. Patients referred from long-term care institutions were on significantly more drugs than non-institutionalized subjects. A 34% reduction in the number of medicines prescribed at discharge was accompanied by a significant decrease in the mean number of prescriptions per patient, from 4.3 to 2.8, irrespective of whether the patient was institutionalized. Polypharmacy, defined by 5 or more concomitant drugs, declined from 43 to 17%. Dosage schedules were simplified in the majority of patients, as expressed by a significant decrease in the mean number of daily doses to be taken from 6.7 on admission to 4.4 at discharge. Cardiovascular drugs, diuretics and psychotropic drugs accounted for 64% of all drug prescriptions. At discharge, prescription frequencies were reduced for most medication categories, except diuretics and gastrointestinal drugs, which were being taken more often. The prescribing frequency of cardiac glycosides, the single most frequently prescribed drug class, decreased from 60 to 33% of the patients. Three months after discharge, prescribing patterns and frequencies were found to be very similar to the pre-admission situation. Eighteen months after discharge, overall drug use had increased by 15% compared to admission, and polypharmacy was recorded in 54% of patients. It is concluded that a substantial reduction in drug prescriptions was possible in the majority of elderly patients, particularly if they are institutionalized, on admission to a geriatric clinic.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of low fat diet and intensive physical exercise were examined in a randomized prospective study in patients with angiographically documented coronary heart disease. In addition to supervised regular physical exercise, patients of the intervention group (n = 18) were subjected to intensive dietary counselling with the aim of a low fat, low cholesterol diet to be maintained for at least 12 months. The control group (n = 27) received relevant advise only and usual care by private physicians. In the intervention group there was significant lowering of plasma triglycerides (202 +/- 82/141 +/- 74 mg/dl) and body weight (78.2 +/- 9.5/73.7 +/- 10.4 kg) while total and LDL cholesterol did not change significantly. There was a tendency for a rise of HDL-cholesterol (35.6 +/- 9.0/40.4 +/- 14.8 mg/dl, p = 0.07). According to 24-hour diet protocols there was a significant lowering of energy intake (2.298 +/- 697/1.602 +/- 758 kcal/day), of fat intake (111.7 +/- 44.4/52.0 +/- 23.9 g/day) and of intake of dietary cholesterol (402.8 +/- 186/161.3 +/- 100.3 mg/day) as well as of saturated fatty acids (42.5 +/- 20.4/14.3 +/- 8.1 g/day). Fatty acid composition of adipose tissue was not correlated with the patients' 24-hour dietary protocols. In the control group there were no changes of plasma lipids, body weight or diet composition according to 24-hour protocols after 1 year compared to data at the beginning of the study. There was, however, a marked correlation of adipose tissue composition and dietary information given by the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Die verschiedenen klinischen Manifestationen der Arteriosklerose werden mit zunehmendem Alter immer haufiger. Die Evidenz des Erfolgs einer Therapie durch Beeinflussung der zugrunde liegenden Risikofaktoren, insbesondere der Dyslipoproteinamie, stammt aus zahlreichen Studien der letzten Jahre und erstreckt sich auch auf „rustige“ Senioren. Fur multimorbide Hochbetagte ist die Datenlage weniger eindeutig. Nach derzeitigem Wissen sollten auch alte Patienten, insbesondere im Rahmen einer Sekundarpravention, von Masnahmen profitieren, die zur Senkung erhohter Cholesterinspiegel fuhren, sofern diese im Kontext von Multimorbiditat, Gebrechlichkeit und sehr begrenzter Lebenserwartung sinnvoll und moglich sind.

In the therapy of malnutrition in the elderly oral treatment should be preferred. It represents a particular challenge to relatives, caregivers and physicians. Because of the individual deficits in each patient a personal adapted plan has to be established. Treatment includes an optimized food supply, energy-rich and enriched meals, and liquid nutritional supplements but also special care during the meal and an inviting environment. The success is very much dependent on the intensity of care.

The review of medication has been recommended as an important part in preventing falls. In a random sample of 276 hospital in-patients aged 75 and over, the frequency of prescribed drugs which may increase the risk of falling by causing dizziness was assessed. Questions about dizziness and previous falls were included in a standardized questionnaire. Patients with dizziness reported falls 10 times more often than patients without dizziness. Prescribed medications possibly causing dizziness were very common. Neuroleptics, antidepressants, hypnotics/sedatives, and combinations of drugs with hypotensive efficacy were significantly more often prescribed in patients who reported dizziness. Systematical review of medications appears to be worthwhile, particularly in cases with multiple drug prescriptions.

Every geriatric patient should routinely be questioned about possible urinary incontinence. The basic diagnostic work-up comprises the clinical history, wherever indicated a geriatric assessment, a nursing care history, a physical examination and a micturition protocol. Furthermore, determination of postvoid residual urine, laboratory investigations and a urine-analysis should be done in all patients. Ultrasonography of the urinary tract is a simple non-invasive procedure that can exclude the presence of large tumors, stones in the bladder and urinary retention. Only selected patients require a greater diagnostic effort prior to treatment, for example, urologic and/or gynecologic investigations or a urodynamic evaluation.

The therapeutic strategy rests on a simple basic diagnostic investigation. As a rule, the greatest importance attaches to toilet training and individual counseling. In this context, the work of a specialist nurse capable of providing both the patient and his/her relatives with competent instruction is of considerable importance. A greater diagnostic effort is needed only for selected prior to the initiation of therapy. Even in the elderly patient urinary incontinence is curable or can at least be improved; it is not an inevitability of old age.

A four-week basic course in geriatric medicine was developed, that is interdisciplinary and with many practical aspects. The participants have rated the interdisciplinary concept very positively, at the end of the course and 13 months after the course. Interdisciplinary learning is possible, makes sense and promotes the necessary geriatric teamwork; specific professional training can, however, not be substituted.

This randomized study was performed to assess the effects of3 hours of physical exercise per week and low-fat diet on collateral formation in nonselected patients with coronary artery disease (intervention group, n = 56). Results were compared with those of patients in a control group (n = 57), who received usual care by their private physicians. Coronary lesions were assessed by quantitative coronary angiography at the beginning and after 1 year of study (n = 92). As previously reported, after 1 year there was a significant retardation of progression of coronary artery disease in the intervention group as compared with the control group. In this study, evaluation of collateral formation revealed no significant difference between both groups, and changes in hemodynamic and metabolic variables or leisure time physical activity were not related to changes in collateral formation. Although progression of the disease was significantly related to an increase in collateral formation, regression was significantly related to a decrease in collateral formation (p0.00001). Because patients in the intervention group exercised for3 hours/week, and patients with regression of coronary artery disease even dedicated 5 to 6 hours to leisure time physical activity per week, these findings question whether an exercise program within the safety tolerance of patients will be able to induce coronary collateralization in the presence of regression of coronary artery disease.

A balanced diet before one gets old is relevant for the prevention of the diseases of affluence in old age. With decreasing physical activity the energy requirement decreases, and foods with high nutrient density are required to still supply all essential nutrients. Thirst may become a poor guide to sufficient fluid intake, which should be maintained by good drinking habits. As a consequence of disease or functional impairments, malnutrition may develop. Weight loss and anorexia are warning signals. Risk factors for malnutrition should be known and, if possible, eliminated. A poor nutritional status in the elderly increases morbidity and mortality: good nutrition in the last decades, on the other hand, is an important determinant of the quality of life.

The purpose of this prospective study was to measure patients’ ability to open a purse, take out money, and count it, in order to identify persons in need of increased health care. The study population consisted of 183 patients (mean age 78.9; range: 66-95) in two settings: 78 consecutively admitted geriatric hospital patients who could return home, and 105 community-dwelling patients aged 70 years or older. None was completely dependent on others, nor severely demented. Time for task performance was measured. Further assessment included the Mini-mental State Examination (MMSE), Barthel index of ADL, instrumental activities of daily living (IADL), socioeconomic status, grip strength, Williams board test, and medication profile. The Timed Test of Money Counting (TTMC) was reliable (interrater and intrarater), and showed construct and concurrent validity with other measures of physical function. There was a strong correlation (p

The transition team has its place in pre- and postdischarge nursing and therapeutic care, on the basis of a geriatric assessment. Core members of the team are, in the sequence of the scheduled performance in-hospital, nurse, occupational therapist, physiotherapist and social worker, supplemented by a team physician. Two-thirds of all treatments were in the hospital, one-third in an outpatient setting up to 4 weeks after discharge. Cooperation with outpatient services has been good.

In this ongoing randomized controlled trial the effectiveness of an interdisciplinary team implementing hospital-based comprehensive geriatric assessment (CGA) and home intervention is being studied. All patients admitted from home showing functional decline with impairment of any basic activity of daily living are randomly assigned to one of the following courses of treatment: CGA with in-hospital and post discharge management by a home intervention team (HIT), where necessary (group 1): CGA with recommendations and usual care at home (group 2); or usual hospital and home care (group 3). The HIT consists of 3 nurses, 1 geriatrician, 1 physiotherapist, 1 occupational therapist, and 1 social worker. 540 patients will be recruited for the trial, which will assess the effects of GEM-HIT on the following outcomes: health status, functional status, survival, hospital readmission, nursing home placement and costs. The purpose of the GEM-HIT trial is to answer many of the current questions concerning treatment and health care delivery for frail older persons under the specific conditions found in Germany. The large sample size and the broad range of diagnoses included in the study will allow the evaluation of effects of GEM-HIT for subgroups and may help to identify the most effective assessment tools for use within our particular context.

The value of a diagnostic home visit as part of hospital-based geriatric assessment was examined in a prospective study. 141 subjects admitted from home to the geriatric hospital and showing functional decline with risk of nursing home placement underwent a comprehensive geriatric assessment and a diagnostic home visit. In 19.1% of the patients, the diagnostic visit resulted in a change of time, and in 14.9% in a change of location of discharge. Up to seven problems were newly discovered (mean 2.1). To maintain independence up to six technical aids were prescribed (mean 2.3). The most common recommendations were related to safety (59.2% of all cases). In 89.3% the diagnostic home visit was judged necessary by the home intervention team. A follow-up visit after 3 months revealed that about 80% of all recommendations were implemented and approximately the same amount of technical aids were still used. The diagnostic home visit allows individual prescription of technical aids, when necessary. It contributes meaningful information to the geriatric assessment process and helps to achieve successful in-hospital therapy and discharge planning. It can be recommended especially for elderly patients at risk for losing their independence.

Psychiatric diseases are very common among elderly people. Depressions rank before dementias in this age group. 2-2.5 million people aged over 65 years are suffering from symptoms of depression in Germany. Patients with Mayor Depression Disease (MDD) have a poor prognosis. MDD should therefore be recognized and treated in community dwelling elderly, in nursing homes and in hospitals. Underdiagnosis of MDD is well documented in the medical literature. Only a quarter of patients with a MDD are detected. By a short screening test for depression such as the Geriatric Depression Scale (GDS) depressed patients can be identified. With a sensitivity and specificity of about 70%. The time needed to perform the short form of the GDS is only 5-7 min. The GDS is an important part of many assessment programs in England and USA. It is also recommended in Germany by the "Geriatric Assessment" working group.

To evaluate functional disabilities in elderly patients, geriatric assessment was performed in one general practice. Excluded from the study were patients with severe dementia and dependence. 178 patients were asked to participate and 144 accepted (mean age 78.7 +/- 5.8 years; number of diagnoses 5.2 +/- 2.6; f = 95, m = 49). Mini-mental-status examination showed moderately but significantly lower (p0.05) cognitive capacity in the age groups of 80-84 years (n = 37, 24.56 +/- 4.90 points) and of 85 years and older (n = 30, 25.14 +/- 3.11 points), but not in the group of 75-79 years (n = 46, 26.70 +/- 3.90 points) compared to the group of 70-74 years (n = 31, 27.65 +/- 2.59 points). Neither the Geriatric Depression Scale nor the Barthel-Index (activities of daily living) showed significant differences between the age groups. The score of the instrumental activities of daily living (Lawton Index) was significantly lower (p0.05) in the age group 85 years and older (4.1 +/- 2.5 points) compared to the age group of 70-74 years (6.1 +/- 2.4 points). Grip strength was significantly reduced (p0.01) in the age group 85 years and older as well as motility and balance scores (Tinetti test; p0.05) compared to the group of 70-74 years (43.21 +/- 16.27 kp and 64.87 +/- 19.81 kp, resp., 19.3 +/- 6.6 and 23.1 +/- 5.9 points). No correlation was found between the results of functional assessment and number of contacts with the general practitioner in the past year, number of prescribed drugs and number of diagnoses except for the depression test. There was a significant correlation between test score, number of contacts, and number of diagnoses (p0.05). Functional assessment resulted in new diagnoses of urinary incontinence in 7 patients and of mobility disorders in 17 patients. Cognitive impairment was suspected in 14 patients, depression in 2 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

To evaluate social aspects of elderly patients which are important for diagnosis and therapy within geriatric assessment, a questionnaire was developed and validated. Raters showed a high degree of agreement on the scale, which contains social contacts and support, activities, economic situation, and housing conditions (0.92-0.97; p0.05). Compared to the interrater reliability the test-retest reliability was somewhat lower (0.75), but also significant at the 5% level. The internal consistency showed high values between 0.72-0.89. In order to evaluate the validity of the screening test the answers of the patients were compared with the assessment of the therapeutic team. The team had information from a home visit, patients spouse, relatives, neighbors, community nurses and/or general practitioners. There was a significant relationship (p0.01) between therapeutic assessment and the scale (r = 0.51). Sensitivity, specificity, and total efficiency also attained sufficiently high values at a cut-off of 16/17 for the complete scale (max. 25 points). The test is easily and quickly performed; its acceptance is high. Social data relevant for treatment and discharge planning can thus be obtained and patients can be identified, for whom a home visit seems to be useful.

The long-term effect of a low-fat diet and physical training was investigated in 36 men (mean age 51 +/- 6 years) with coronary heart disease (one-vessel disease, n = 11; two vessel-disease: n = 18; three-vessel disease: n = 7). 18 patients (interventionist, group 1) undertook physical training within a coronary sport group (1 h twice weekly) and daily bicycle ergometry (30 min). They were held to a low-fat diet. In the remaining 18 patients (control, group 2), physical training and low-fat diet depended on own initiative after receiving advice. Over an observation period of 6 years total cholesterol concentration in the 17 patients of group 1 decreased significantly (243 +/- 33 vs. 219 +/- 28 mg/dl; P0.02). Physical performance in 12 patients (group 1) increased from 169 +/- 40 to 202 +/- 42 W in (P0.01). In contrast, total cholesterol increased slightly in group 2 (n = 16) from 245 +/- 31 at the beginning to 247 +/- 39 mg/dl (no significant change) at the end of the 6 years. Physical performance (n = 12) decreased slightly from 165 +/- 45 to 146 +/- 52 W (not significant). The difference between the two groups was significant after 6 years (P0.02 and P0.007, respectively). There seemed to be a tendency for progression of the coronary heart disease to be slower in the interventionist than the control group.

The causes of early rehospitalization (within 3 weeks) of very elderly patients, its possible avoidance and appropriate preventive measures were analysed retrospectively in patients of a geriatric hospital. Included were all those patients who had been admitted to the hospital from their home several (mean: five) times between 1987 and 1990 (48 women, 19 men; mean age 81.3 +/- 7.2 years--a total of 331 re-admissions). The most frequent diagnoses were heart failure (38.8%), acute cerebrovascular accident or its sequelae (31.3%), dementia (23.9%), fall or its sequelae (22.3%) and diabetes (20.9%). Of the 331 re-admissions 87 (26.3%) occurred during the first 3 weeks after discharge. The most important reasons of this early re-admissions were inadequate home care (41.4%), undesirable drug effects and non-compliance (25.3%), as well as rapid progression of the basic disease (14.9%). In the judgement of the hospital team more than 40% of the early re-admissions were avoidable, among those re-admitted because of inadequate home care and those in connection with drug intake even more than half. Early hospitalization is frequently avoidable, if individual geriatric assessment is undertaken and discharge carefully planned.

Masnahmen fur Gesundheit im Alter bestehen zum einen in der Verhutung bzw. im Abbau kardiovaskularer und anderer Risikofaktoren vor dem Alter (primare Pravention), zum zweiten in einer Minimierung der Abnahme von Gesundheit bei chronischen Erkrankungen durch adaquate Rehabilitation und drittens in einem Masnahmenbundel fur die sekundare Pravention, also in der Vorbeugung von Rezidiven oder einer Verschlimmerung bestehender chronischer Erkrankungen und Behinderungen. Voraussetzung hierfur sind eine umfassende geriatrische Untersuchung jedes Patienten und das Wissen um die wesentlichen Risiken Betagter und Hochbetagter.