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Background: Single or frequent falls lead to increased morbidity due to fall-related injury, fear of falling, impairments in quality of life and loss of independence. To assess the impact of falls, prevalence data are essential., Methods: In 2006, a telephone survey was performed in a random sample of 1270 inhabitants of the city of Herne, Germany, aged 40 years or older. Participants were asked about falls during the previous 4 weeks and 6 and 12 months, respectively. A fall was defined as an unexpected event in which the individual comes to rest on the ground, floor or a lower level. Participants were also asked about pain and whether or not a medical diagnosis of osteoporosis had ever been made. Standardized prevalences and odds ratios (OR) with 95 % confidence interval are reported., Results: In total, 862 (67.9 %) adults participated. Participants were significantly older than non-participants and more often female than male. Prevalences standardized for the population of Herne for at least one fall within the previous 4 weeks or 12 months or two or more falls within 12 months, respectively, were 3.1 %, 12.1 %, and 4.5 %. Women were more often affected than men. A total of 2.3 % participants reported both at least one fall and a medical diagnosis of osteoporosis. The prevalence of falls increased with increasing age and was also related to musculoskeletal pain., Conclusions: Our estimates indicate that single and multiple falls affect a substantial proportion of adults in the urban population. Risk groups such as older adults and females with osteoporosis might represent a target group when considering measures for fall prevention.

Background: To assess cognitive impairment or dementia in epidemiologic studies using telephone interviews for data acquisition, valid, reliable and short instruments suitable for telephone administration are required. For the Telephone Interview for Cognitive Status (TICS) in its modified German version, the only instrument used in Germany so far, more data on reliability and practicability are needed., Material and Methods: Participants were recruited in the offices of nine primary care physicians. Data from 197 participants (115 females, mean age 78.5±4.1 years) who were tested by telephone and in the office by means of the Mini-Mental State Examination (MMSE) were used for the evaluation. For assessing reliability, a group of 91 participants (55 females, mean age 78.1±4.1 years) was contacted twice during 30 days to be tested during a telephone interview by means of the TICS in its modified German version., Results: The intraclass correlation coefficient (ICC), a measure of reliability, was 0.67 [95% confidence interval (CI): 0.53; 0.77]. The Bland-Altman plot did not reveal any relationship between the variability of the difference between repeated measures and the total amount of the measure. For the overall TICS score, no differences were found between repeated measurements. However, the tasks recall of the word list and counting backwards showed some improvement in the repeated tests. TICS and MMSE showed only moderate correlation, with a correlation coefficient of 0.48 (95% CI: 0.36; 0.58). TICS values were dependent on age and educational level of the person tested., Conclusions: The TICS in its modified German version appears to be of acceptable reliability for the assessment of cognitive impairment during a telephone interview. TICS values depend on age and educational level of the person tested. TICS and MMSE correlate only moderately.

A large number of published overview and original articles provide evidence and declare the need for immediate, appropriate preventive lifestyle measures to prevent the development of dementia and Alzheimer's disease (AD). However, despite this, there are great difficulties in drafting effective guidelines in this field. This is mainly due to a lack of not only (comparable) randomized controlled trials but also a lack of homogeneous measures of type and degree of managed risk. Several risk factors for dementia are non-modifiable, such as genes and age. Factors related to lifestyle habits and vascular risk factors are classified as modifiable risk factors. While waiting for effective drug therapies and first-level evidence data, geriatricians, general practitioners, neurologists, and health professionals should be encouraged to improve early diagnosis of cognitive impairment and activate control strategies against vascular disease and unhealthy lifestyle habits.

Background: The concurrent presence or manifestation of multiple chronic conditions, i.e. multimorbidity, poses a challenge to affected patients and their relatives, physicians, and practitioners, and to the health care system in general. Aiming to improve medical care for different chronic diseases, the Chronic Care Model also appears to be suited for multimorbidity. The established research consortium PRISCUS is trying to create some of the prerequisites for a new care model for multimorbid, elderly patients oriented along the lines of the Chronic Care Model., Methods and Results: Four out of seven subprojects of the research consortium provide an overview of some of their findings. Topics in a sports medicine subproject were the assessment of physical activity by means of a newly developed questionnaire and the development and feasibility testing of an exercise program for elderly people with chronic conditions and mobility impairment. Partners from family medicine implemented geriatric assessment in a primary care setting and evaluated its consequences. In a pharmacological subproject, potentially inappropriate medication as well as drug-drug interactions and dosing errors were addressed. The health economic subproject investigated quality of life impairment due to multiple chronic diseases and the effects of multimorbidity on costs., Conclusions: The results of the PRISCUS research consortium allow a better description of consequences of multimorbidity and illustrate at least some new approaches towards prevention, diagnosis, and treatment of patients suffering from multimorbidity. Ongoing projects will test the efficacy of a physical activity program and a new complex intervention to reduce potentially inappropriate medication in the elderly. With this, the research consortium will create some prerequisites for a new health care model for patients with multimorbidity comparable to the Chronic Care Model.

Background: Aspiration pneumonia is associated with a high morbidity and mortality in elderly patients. In order to provide risk-adapted medical care, it is necessary to establish valid prognostic tools for these patients., Objective: The value of two well-established scores to assess prognosis in community-acquired pneumonia (CAP), i.e., CURB-65 and the Pneumonia Severity Index (PSI), was evaluated in elderly patients hospitalized for aspiration pneumonia., Material and Methods: A total of 209 patients hospitalized with aspiration pneumonia between 2001 and 2005 in a single center were evaluated using PSI and CURB-65. For comparison of morbidity and mortality, an equally large group of inpatients with CAP was analyzed., Results: The mean age of patients with aspiration pneumonia was 76.7 ± 13.4 years, and 104 (49.8 %) were female. Patients with aspiration pneumonia more frequently showed a history of cancer, hypotension, and hyponatriemia on admission. Mortality was clearly higher in comparison to patients with CAP (39.2% vs. 16.3%). The Odds Ratio (OR) for mortality was 1.03 (95% CI 0.59; 1.79) for a CURB-65 score of 3-5 points compared to 0-2 points. In cases of CAP, OR showed a statistically significant increase of risk (OR 2.50; 95% CI 1.04; 6.06), for CURB-65 scores of 3-5 points vs. 0-2 points). In aspiration pneumonia, the PSI showed a trend towards increasing mortality within higher risk class., Conclusions: In geriatric patients hospitalized with aspiration pneumonia, CURB-65 and PSI have no prognostic value.

Background: Multimorbidity, the concurrent manifestation or presence of multiple chronic conditions, poses huge challenges to affected patients, their relatives, physicians, and practitioners alike. The growing number of affected persons and the complexity of their needs places just as much of a burden on the health care system as does the plethora of often poorly coordinated interventions. The Chronic Care Model developed for different chronic diseases is suited for improving medical care. The PRISCUS research consortium was established to create the prerequisites for a new care model for multimorbid, elderly patients oriented along those lines., Methods: The research consortium utilizes data gathered in a large-scale epidemiological study on peripheral arterial disease (getABI study) and from the Dortmund and Münster stroke registries, by extracting epidemiologic and health economic data, quality-of-life parameters, and data on the extent and quality of medication. Additional projects evaluate the implementation of a multidimensional geriatric assessment in primary care, the functional consequences of multimorbidity in stroke patients along with options for prevention and therapy afforded by physical activity. Systematic reviews of the literature are used to describe quality of life and patient preferences. Experts will work on an initial draft treatment standard for patients with multimorbidity and a list of potentially inappropriate medication for the elderly in Germany., Conclusion: The results of the PRISCUS research consortium will enable an epidemiologic characterization and description of consequences of multimorbidity, while illustrating new approaches towards prevention, diagnosis, and management of multimorbid patients. With this, some prerequisites for a new health care model for patients with multimorbidity comparable to the Chronic Care Model will be fulfilled.

Background: Musculoskeletal pain is among the most common symptoms in the population and osteoarthritis is the most important underlying disease. Due to demographic changes, an increase in problems with arthritis is to be expected. To assess the impact on individuals affected and the community, data on the prevalence of musculoskeletal pain and osteoarthritis are essential., Methods: We performed a telephone survey in a sample of 1,270 inhabitants of the City of Herne, Germany, aged 40 years and older. Participants were asked to give their experience on musculoskeletal pain at the time of the questionnaire and during the last 4 weeks and 12 months. Further questions were whether the knee or hip were the site of most severe pain and if osteoarthritis was ever diagnosed by a physician. Standardized prevalences are reported according to age., Results: A total of 862 (67.9%) persons participated and participants were significantly older and more often female. Musculoskeletal pain on the day of the questionnaire, during the past 4 weeks and the past 12 months was reported in 37.4%, 53.0% and 60.0%, respectively. The knee and hip were predominantly affected in 35.9% and 16.1%, respectively and 26.2% reported that a physician had previously diagnosed osteoarthritis. The prevalences were related to age and gender., Conclusions: Musculoskeletal pain and osteoarthritis affect an important part of the adult urban population. We found associations between self-reported musculoskeletal pain, osteoarthritis, age and gender. Further studies should evaluate the interference of pain with activities of daily living as well as the use of health services by affected patients.

In the present cross-sectional study the results of three tests to assess the risk of falling were examined for a correlation with advancing age of the participants. Each of the 188 community dwelling active participants aged 40 years or older with a history of knee pain performed the Timed Up and Go (TUG), the Performance Oriented Mobility Assessment (POMA, "Tinetti Test") and a less established simple test of dynamic balance, the Four Square Step Test (FSST). Age-related differences in performance in the Timed Up and Go and the Performance Oriented Mobility Assessment have been shown in previous studies and are also present in this sample. For the Four Square Step Test an association of test performance and age has been shown for the first time in this study. Further investigation is required to determine the quality of these three tests regarding their ability to assess the risk of falling in patients with knee pain.

Osteoporosis is one of the ten leading diseases with an enormous epidemiological and economic burden for societies. Research in recent years has shown that osteoporosis is not part of the "normal" aging process, but a disease with an evidence-based body of knowledge concerning diagnostics and therapy. Because the correlation of the frequency with age is high and because of the demographic dynamics in the coming years in Germany, the importance of this disease will dramatically increase. From a societal point of view, several endpoints have to be to considered, especially mortality and loss of independence after fracture. The importance of the social and economical consequences of hip fractures (excess mortality, loss of independence, institutionalization) will increase in the near future. Therefore, it is necessary to have an adequate database for different sectors of the health system (ambulatory, hospital, rehabilitation). A health system will then be able to decide on effective and efficient ways of allocating resources. The experiences of two research projects with registry data show that it is possible to demonstrate the deficits and problems of current medical care and to develop strategies for an optimization in the future.

The success of evidence-based medicine (EbM) will also depend whether its effectiveness is proven in empirical studies. The main question is how the information-seeking behaviour of physicians can be modified. A series of studies have shown that their information management is frequently not based on a rational model of knowledge acquisition. In particular, many studies concerning the implementation of guidelines as a practical application of EbM have demonstrated that, in addition to a general skepticism about guidelines, many practical obstacles are relevant. An optimal implementation strategy should consider these from the beginning.

The parties of the self-governing Health Service are at present preparing the introduction of a general case, flat rate compensation system for the hospital section on behalf of the legislature. The system is based on the performance definitions and case classifications of the Australian DRG System, Version 4.1. The relative evaluation of the individual DRG for the implementation into the system in Germany will be based on German cost and benefit data. For this purpose a calculation of case-specific treatment costs based on a representative selection of hospitals will be made. The geriatrics field will have to adapt itself to these regulations in the same way as all other medical disciplines. Difficulties are arising due to the inconsistent classification of cost and benefit data in connection with the classification. The geriatric field is under-represented in the calculation of relative evaluation and, therefore, the spectrum of benefit cannot be shown in the planned calculation system. Analogous to the calculation of German relative cost evaluation, the geriatric section will define in a project the actual costs for their treatment cases and determine the consecutive relative evaluation.

In Germany, health services research geriatric problems is not of major scientific and political importance. Focusing on geriatrics, it is essential to produce good data concerning efficacy, effectiveness and costs of the interventions. Otherwise, the discussion about the allocation of resources in the German health care system will take place without good arguments for special geriatric interventions. Prerequisite for this goal is the definition of adequate endpoints targeting functional deficits and the operationalization of multi- and comorbidity. Another problem is research focused on the "black box" of specific geriatric interventions. A special German situation is the distinction between acute and rehabilitative geriatric settings where very similar patients are treated. For this reason, it is essential for the geriatrician in the German context to focus more on health services research to demonstrate with scientific evidence their important contribution for the care of the elderly.

The relationship between quality of life and aging is difficult to describe with the usual epidemiological concepts like mortality. A functional approach is more important and meaningful for the analysis of the aging process. The ICIDH classification has the advantage of combining the diseases process itself and the consequences concerning functional limitations. Studies about the "active life expectancy" show that quality of life and life expectancy are two different dimensions of the aging process. For the purpose of prevention, it is important to demonstrate that preventive interventions could help reduce the number of years with functional limitations. Most of the epidemiological studies indicate that even lost functions could be restored. For these interventions, it is important to individualize the goals for preventive measures to balance physical and emotional needs of the elderly.

The use of evidence-based medicine (EBM) in the field of geriatrics faces some specific problems. Deficits in representation of older people in medical trials and the attitude of the majority of patients and their physicians considering disease as normal aging counteract successful implementation. EBM is also feasible in older patients after some adjustments without dropping the principles of the method or the preferences of patients, thus, resulting in improvement in diagnostic and therapeutic decisions. The methods are exemplified in the use of prophylactic antibiotics in endoscopic gastrostomy, a relevant geriatric problem with practical consequences.

Objective: To assess the direct and indirect costs of hip fracture in dependence of postoperative care setting., Study Design: Prospective cohort study., Methods: 227 consecutive patients in three hospitals (city, town, and small town) presenting with hip fracture. For 177 patients there was follow-up regarding post-operative care-setting. During follow-up the cost of the remaining patient at 1, 3, 6 month were recorded and afterwards adjusted to the distribution of the initial cohort. To obtain information on patient characteristics, assessment during hospital stay and follow up have been performed., Results: There was a relevant difference in costs depending on the care setting after hip fracture. The nursing home - nursing home, community - community, and community - nursing home resulted in total costs at 6 month of 17,701 DM, 27,102 DM and 54, 503 DM, respectively (average: 24,508 DM). Nursing home costs contributed significantly to the differences between groups. Valid and predictive measures could not be established in first analysis of performed assessments., Conclusion: Due to the high incidence of hip fractures (100,000/y) indirect costs play a major role in the economic impact of this illness. The analysis of the effectiveness of interventions has to take into account these costs to achieve adequate conclusions.

The further development of 162 stroke patients (average age 77 years), who were geriatrically assessed during hospitalization, was evaluated ca. 18 months after stroke. Questionnaires were mailed to patients. 53% of the patients (n = 86) returned the questionnaire duly filled in; 20% (n = 32) had died; in the remaining 27% of cases (n = 44) no information was obtained on further development. 80% of those patients who responded lived at home despite numerous medical problems. Family members assumed most of the care required. Follow-up treatment and pain therapy proved to be particularly problematic. The Barthel Index according to data collected was significantly lower compared to figures noted upon release from the hospital. Hardly anyone among those patients received follow-up treatment. 74% of patients complained of pain although the majority has regular contacts with the family doctor. For those patients who died in the 18 months interval, significantly lower values for the activities of daily living (ADL) has already been recorded upon hospitalization. They had a less favorable view of their state of health and were less satisfied with life in general.

Objective: Scores like APACHE (Acute Physiology And Chronic Health Evaluation) were evaluated for unselected intensive care unit (ICU) admissions. Can they also be used for risk stratification and quality assurance in selected subgroups like elderly patients?, Methods: Over a 3-year period data of all admissions of a 12 bed interdisciplinary ICU were collected. APACHE II and III scores and probabilities of hospital deaths were compared with observed outcomes. The discriminatory power was evaluated by calculating the areas under the receiver operating characteristic (ROC) curves. Calibration was analyzed with standardized mortality ratios (SMR) and the Hosmer-Lemeshow goodness-of-fit statistic., Results: Of 3382 admissions due to exclusion criteria, 2795 patients were analyzed, 1396 (49.9%) of these were > or = 65 years, mean age 75 (65-99) years. 62.5% were non-operative, 37.5% postoperative admissions, 35% after emergency operations. ICU mortality was 11.7%, hospital mortality 25.1%. The areas under the ROC curves were 0.77 for APACHE II and 0.79 for APACHE III (whole collective 0.83 and 0.85, respectively). The SMR was 1.17 for APACHE II and 1.23 for APACHE III compared with 1.06 and 1.22 for all patients, respectively. Calibration for elderly patients was insufficient for APACHE II (Hosmer-Lemeshow chi-square = 19, p < 0.025) as well as for APACHE III (chi-square = 41, p < 0.001), while it was good for all patients for APACHE II (chi-square = 12, p > 0.1) but not so for APACHE III (chi-square = 48, p < 0.001)., Conclusions: APACHE II and III both show good discrimination for elderly patients although a little inferior than for all patients. Both scores can be used for risk stratification of elderly ICU patients. Mortality prognosis is not sufficient for geriatric patients although APACHE II calibrates well for all. Application of these scores for quality assurance in selected subgroups like elderly patients cannot be recommended based on these data.

The aim of the present study was to describe the course and outcome of rehabilitation using a national recommended assessment program (AGAST). In our study 162 patients with stroke were included. Nearly all patients had improvement of activities of daily living (Barthel Index) and mobility (Tinetti Gait and Balance Score, Frenchay Arm Test). A similar trend was observed in patients with cognitive impairment and depression on admission. Of the different tests, the Barthel Index and mobility scores were shown to be important predictors of length of hospital stay. Further evaluation of the assessment instruments is needed to assess different aspects of quality of life (self-rated well-being, satisfaction). To assess the efficiency of geriatric rehabilitation in patients with stroke, it will be important to measure resource consumption and to evaluate the long-term results.

Functional deficits of elderly patients are often not recognized during routine treatment in acute hospital care. In Germany, there are only limited experiences with the use of standardized assessment-scales in this health care setting. In this study, 112 patients were recruited for a very broad geriatric assessment focused on methodological and practical questions. There were 38.8% with deficits in the ADL and 12.6% with depressive symptoms. Many patients showed low motivational factors such as energy, efficacy and will. Geriatric syndromes such as malnutrition were also very common. In general, many patients in acute care hospitals have functional deficits which are not recognized by the physicians. For many patients, short instruments are sufficient for screening purposes. The effectiveness of a complete geriatric assessment depends mostly on the use of good selection criteria.

This work presents preliminary recommendations for a three-step geriatric assessment approach developed by a newly created working group consisting of members from nine geriatric departments in Germany and Switzerland. The recommendations were based on a literature review, expert consultation, and a consensus meeting. As part of this effort, instruments and guidelines for selected geriatric assessment instruments were translated and will be tested in German language. Further research is planned for refining the recommended method. Currently, these recommendations might help to stimulate the spread of geriatric assessment method in German-speaking areas and facilitate joint research projects among geriatric institutions.