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We estimate the dementia incidence hazard in Germany for the birth cohorts 1900 until 1954 from a simple sample of Germany’s largest health insurance company. Followed from 2004 to 2012, 36,000 uncensored dementia incidences are observed and further 200,000 right-censored insurants included. From a multiplicative hazard model we find a positive and linear trend in the dementia hazard over the cohorts. The main focus of the study is on 11,000 left-censored persons who have already suffered from the disease in 2004. After including the left-censored observations, the slope of the trend declines markedly due to Simpson’s paradox, left-censored persons are imbalanced between the cohorts. When including left-censoring, the dementia hazard increases differently for different ages, we consider omitted covariates to be the reason. For the standard errors from large sample theory, left-censoring requires an adjustment to the conditional information matrix equality.

Background Recent evidence indicates an important role for neuroinflammation in the pathological cascade of Alzheimer's disease (AD), and neuroinflammation is increasingly being recognized as a potential therapeutic target. Objective To assess the impact of glucocorticoids on the risk of developing dementia. Methods We used health insurance data of the largest German health insurer from 2004-2013 with a baseline sample of 176,485 persons aged 50 years and older to study the association of glucocorticoid treatment and incidence of dementia. Cox proportional-hazard models were calculated adjusting for sex, age, and comorbidities known to be major risk factors for dementia and were given as hazard ratios (HR) with 95% confidence intervals (CI). We further stratified glucocorticoid treatment by route of application and treatment duration. Results Of the 176,485 dementia-free persons, 19,938 were diagnosed with dementia by the end of 2013. The risk of suffering from dementia was significantly lower for glucocorticoid users compared to non-users (HR = 0.81, CI = 0.78-0.84). The lowest risk was found among users of inhaled glucocorticoid (HR = 0.65, CI = 0.57-0.75), followed by nasal (HR = 0.76, CI = 0.66-0.87), other (HR = 0.84, CI = 0.80-0.88), and oral users (HR = 0.83, CI = 0.78-0.88). We found no difference in risk reduction between long- and short-term-users. Conclusion Longitudinal German health insurance data indicate that the use of glucocorticoids is associated with a lower risk of dementia. Prospective clinical trials will be necessary to determine whether glucocorticoids can have a positive impact on neuroinflammation and thus protect persons against dementia.

Background We assess the impact of prevention strategies regarding type 2 diabetes as a modifiable risk factor for dementia and its consequences for the future number of dementia patients in Germany. Methods We used a random sample of health claims data (N = 250,000) of insured persons aged 50 + drawn in 2014, and data on population size and death rates in 2015 from the Human Mortality Database. Using exponential hazard models, we calculated age- and sex-specific transition probabilities and death rates between the states (no diabetes/no dementia, diabetes/no dementia, no diabetes/dementia, diabetes/dementia). In multi-state projections, we estimated the future number of dementia cases aged 75 + through 2040 depending on the development of the incidence of diabetes among persons without diabetes and without dementia, and the dementia incidence among persons with and without diabetes. Results In 2015 there were 1.34 million people with dementia aged 75 + in Germany. A relative annual reduction in death rates of 2.5% will increase this number to 2.68 million by 2040. A relative reduction of diabetes incidence by 1% annually would decrease dementia cases by around 26,000, while a reduction of dementia incidence among people with diabetes by 1% would result in 175,000 fewer dementia cases. Both prevention strategies combined would prevent 191,000 dementia cases in 2040. Conclusions The increase in life expectancy is decisive for the future number of people with dementia. Strategies of better diabetes treatment have the potential to lower the number of dementia patients in the coming decades.

Zusammenfassung Ziel der Studie Bislang fehlen diagnosespezifische Analysen zum Risiko für Erwerbsminderungsrente (EMR). Unsere Studie konzentriert sich auf Personen, die bereits eine medizinische Rehabilitation (Reha) aufgrund von Herz-Kreislauf-Krankheiten absolviert haben. Methodik Wir nutzen den für Forschungszwecke verfügbaren Datensatz „Abgeschlossene Rehabilitationen im Versicherungsverlauf 2006–2013“ der Deutschen Rentenversicherung (DRV). Mittels Ereignisdatenanalyse haben wir die Übergänge in Erwerbsminderungsrente diagnoseübergreifend sowie diagnosespezifisch untersucht. Dabei nutzen wir Kaplan-Meier-Schätzer und altersstandardisierte sowie geschlechtsspezifische Übergangsraten. Multivariat schätzen wir mittels Cox-Regressionen die Effekte von soziodemografischen Determinanten auf das Risiko für EMR, um besonders relevante Risikofaktoren herauszuarbeiten. Ergebnisse Besonders rasche Übergänge in EMR nach der Reha wurden für die Diagnosegruppen Hirninfarkt, Kardiomyopathie sowie zerebrovaskuläre Krankheiten festgestellt. Besonders relevante Risikofaktoren für EMR sind eine niedrige Bildung, Teilzeit- oder keine Erwerbstätigkeit vor der Reha sowie ein ostdeutscher Wohnort. Schlussfolgerung Besonderer Bedarf erfolgreicher medizinischer Rehabilitation zeigt sich für Patienten mit Hirninfarkt, Kardiomyopathie oder zerebrovaskulären Krankheiten. Bei Multimorbiditäten sollte gerade auf diese Diagnosen ein besonderes Augenmerk gelegt werden. Die Reintegration sozial schwacher Personengruppen in das Erwerbsleben zur Vermeidung von EMR scheint sich darüber hinaus als besonders schwierig darzustellen.

In recent years, Germany and Austria have been among the leading European receiving countries for asylum seekers and refugees (AS&R). The two countries have cultural and economic similarities, but differ, for example, in their health care systems, with AS&R having unrestricted access to health services upon arrival in Austria, but not in Germany. This study investigates the determinants of health among refugees in Austria and Germany, and how these determinants differ between the two countries. We analyze comparable and harmonized survey data from both countries for Syrian, Afghan, and Iraqi nationals aged 18 to 59 years who had immigrated between 2013 and 2016 (Germany: n = 2,854; Austria: n = 374). The study adopts a cross-sectional design, and uses propensity score matching to examine comparable AS&R in the two receiving countries. The results reveal that the AS&R in Germany (72%) were significantly less likely to report being in (very) good health than their peers in Austria (89%). Age and education had large impacts on health, whereas the effects of length of stay and length of asylum process were smaller. Compositional differences in terms of age, sex, nationality, education, and partnership situation explained the country differences only in part. After applying propensity score matching to adjust for structural differences and to assess non-confounded country effects, the probability of reporting (very) good health was still 12 percentage points lower in Germany than in Austria. We conclude that many of the determinants of health among AS&R correspond to those in the non-migrant population, and thus call for the implementation of similar health policies. The health disadvantage found among the AS&R in Germany suggests that removing their initially restricted access to health care may improve their health.

Objective This study aims to estimate the incidence of severe binocular vision impairment and blindness (SVI/B) and to identify eye diseases and regional risk factors of persons with SVI/B at ages 50 years and older. Methods We designed an observational cohort study based on longitudinal, multifactorial, and administrative information of a random sample of 250,000 persons at ages 50+. All individuals were included in the process-produced health claims register of the Allgemeine Ortskrankenkasse in 2004, and were followed until 2015. We analyzed ten selected eye diseases and regional characteristics as risk factors for SVI/B using Cox models, adjusting for demographic characteristics and multi-morbidity. Results The age-standardized incidence was 79 new diagnoses of SVI/B per 100,000 person-years (95%-CI: 76-82); 77 for males (72-82) and 81 for females (77-85). By adjusting for multiple factors, the model revealed and confirmed that individuals who were very old (Hazard ratio90+: 6.67; 3.59-12.71), male (1.18; 1.01-1.38), had multi-morbidities (three+ diseases: 3.36; 2.51-4.49), or had diabetes (1.26; 1.07-1.49) had an increased risk of SVI/B. Compared to persons without the particular eye disease (all p Conclusion The study revealed and confirmed some profound risk factors of SVI/B at both the individual and the macro level. The sizes of the effects of the characteristics of the living context were smaller than those of the individual characteristics, especially for some severe eye diseases. While urbanity and access to health services had no effect, regional economic wealth was a risk factor for SVI/B. Future health care measures and advice by physicians should take these dimensions of inequalities in SVI/B into account.

BackgroundLittle is known about factors correlated with this geographic spread of the first wave of COVID-19 infections in Germany. Given the lack of individual-level socioeconomic information on COVID-19 cases, we resorted to an ecological study design, exploring regional correlates of COVID-19 diagnoses.Data and MethodWe used data from the Robert-Koch-Institute on COVID-19 diagnoses by sex, age (age groups: 0-4, 5-14, 15-34, 35-59, 60-79, 80+), county (NUTS3 region) differentiating five periods (initial phase: through 15 March; 1st lockdown period: 16 March to 31 March; 2nd lockdown period: from 1 April to 15 April; easing period: 16 April to 30 April; post-lockdown period: 1 May through 23 July). For each period we calculated age-standardized incidence of COVID-19 diagnoses on the county level, using the German age distribution from the year 2018. We characterized the regions by macro variables in nine domains: “Demography”, “Employment”, “Politics, religion, and education”, “Income”, “Settlement structure and environment”, “Health care”, “(structural) Poverty”, “Interrelationship with other regions”, and “Geography”. We trained gradient boosting models to predict the age-standardized incidence rates with the macro structures of the counties, and used SHAP values to characterize the 20 most prominent features in terms of negative/positive correlations with the outcome variable.ResultsThe change in the age-standardized incidence rates over time is reflected in the changing importance of features as indicated by the mean SHAP values for the five periods. The first COVID-19 wave started as a disease in wealthy rural counties in southern Germany, and ventured into poorer urban and agricultural counties during the course of the first wave. The negative social gradient became more pronounced from the 2ndlockdown period onwards, when wealthy counties appeared to be better protected. Population density per se does not appear to be a risk factor, and only in the post-lockdown period did connectedness become an important regional characteristic correlated with higher infections. Features related to economic and educational characteristics of the young population in a county played an important role at the beginning of the pandemic up to the 2ndlockdown phase, as did features related to the population living in nursing homes; those related to international migration and a large proportion of foreigners living in a county became important in the post-lockdown period.DiscussionIn the absence of individual level data, explainable machine learning methods based on regional data may help to better understand the changing nature of the drivers of the pandemic. High mobility of high SES groups may drive the pandemic at the beginning of waves, while mitigation measures and beliefs about the seriousness of the pandemic as well as the compliance with mitigation measures put lower SES groups at higher risks later on.

BackgroundRecent research points towards age- and sex-specific transmission of COVID-19 infections and their outcomes. The effect of sex, however, has been overlooked in past modelling approaches of COVID-19 infections.AimThe aim of our study is to develop an age- and sex-specific model of COVID-19 transmission and to explore how contact changes effect COVID-19 infection and death rates.MethodWe consider a compartment model to establish forecasts of the COVID-19 epidemic, in which the compartments are subdivided into different age groups and genders. Estimated contact patterns, based on other studies, are incorporated to account for age- and sex-specific social behaviour. The model is fitted to real data and used for assessing hypothetical scenarios with regard to lockdown measures.ResultsUnder current mitigation measures as of mid-August, active COVID-19 cases will double by the end of October 2020. Infection rates will be highest among the young and working ages, but will also rise among the old. Sex ratios reveal higher infection risks among women than men at working ages; the opposite holds true at old age. Death rates in all age groups are twice as high among men as women. Small changes in contact rates at working and young ages may have a considerable effect on infections and mortality at old age, with elderly men being always at higher risk of infection and mortality.DiscussionOur results underline the high importance of the non-pharmaceutical mitigation measures in low-infection phases of the pandemic to prevent that an increase in contact rates leads to higher mortality among the elderly. Gender differences in contact rates, in addition to biological mechanisms related to the immune system, may contribute to sex-specific infection rates and their mortality outcome. To further explore possible pathways, more data on COVID-19 transmission is needed which includes socio-demographic information.

ObjectiveWe evaluated the short-, medium-, and long-term effects of sepsis on dementia incidence using German health claims data.MethodsA total of 161,567 patients (65 years or older) were followed from 2004 to 2015 at quarterly intervals. Time since sepsis was categorized into 0 (the effective quarter of sepsis diagnosis), 1–8, and ≥9 quarters since the latest diagnosis of sepsis, taking into account admission to intensive care unit and controlling for delirium, surgery, age, sex, and comorbidities. Incident dementia was defined for all persons who did not have a validated dementia diagnosis in 2004 and 2005 and who received a first-time, valid diagnosis between 2006 and 2015.ResultsDuring the quarter of sepsis diagnosis, patients not admitted to intensive care had a 3.14-fold (95% CI 2.83–3.49) increased risk, and those with intensive care stay had a 2.22-fold (95% CI: 1.83–2.70) increased risk of receiving an incident dementia diagnosis compared with patients without sepsis. The impact of sepsis on incident dementia remained in the following 2 years, remitting only thereafter.ConclusionsFor sepsis survivors, medium-term dementia risk remains elevated, whereas long-term risk may reach the level of those without sepsis, even after controlling for delirium. These findings encourage identifying modifiable components of hospital and rehabilitation care.

BackgroundExposure to fine particulate matter and black carbon is related to cognitive impairment and poor lung function, but less is known about the routes taken by different types of air pollutants to affect cognition.ObjectivesWe tested two possible routes of fine particulate matter (PM2.5) and black carbon (BC) in impairing cognition, and evaluated their importance: a direct route over the olfactory nerve or the blood stream, and an indirect route over the lung.MethodsWe used longitudinal observational data for 31232 people aged 18+ from 2006 to 2015 from the Dutch Lifelines cohort study. By linking current and past home addresses to air pollution exposure data from ELAPSE, long-term average exposure (≥ ten years) to PM2.5 and BC was calculated. Lung function was assessed by spirometry and Global Initiative (GLI) z-scores of forced expiratory volume in 1s (FEV1) and forced vital capacity (FVC) were calculated. Cognitive performance was measured by cognitive processing time (CPT) assessed by the Cogstate Brief Battery. Linear structural equation modeling was performed to test the direct/indirect associations.ResultsHigher exposure to PM2.5 but not BC was directly related to higher CPT and thus slower cognitive processing speed [18.33 (×10−3) SD above the mean (95% CI: 6.84, 29.81)]. The direct association of PM2.5 constituted more than 97% of the total effect. Mediation by lung function was low for PM2.5 with a mediated proportion of 1.78% (FEV1) and 2.62% (FVC), but higher for BC (28.49% and 46.22% respectively).DiscussionOur results emphasize the importance of the lung acting as a mediator in the relationship between both exposure to PM2.5 and BC, and cognitive performance. However, higher exposure to PM2.5 was mainly directly associated with worse cognitive performance, which emphasizes the health-relevance of fine particles due to their ability to reach vital organs directly.

This study estimates the prevalence and mortality of diseases of the deep veins of the legs such as deep vein thrombosis (DVT), postthrombotic syndrome (PTS), and venous leg ulceration (VLU). We used a random sample of 250 000 patients at age 50+ years of the register of the Allgemeine Ortskrankenkasse from 2004 to 2015. Selected manifestations of venous diseases assumed as risk factors for mortality were analyzed using Cox models while adjusting for various basic demographic and health characteristics. The prevalence in 2004 was 0.05% for DVT of the femoral veins, 0.50% for DVT of any deep veins, 0.86% for PTS, and 0.91% for VLU. The mortality rate in 2004 to 2015 was 20.40 deaths/100 person-years for DVT of the femoral veins, 10.69 for DVT of any deep veins, 4.34 for PTS, and 7.02 for VLU. The model revealed a 35% higher risk ( p < .001) in patients with any DVT, an 88% higher mortality ( p < .001) for femoral DVT, a 23% higher risk ( p < .001) for VLU, and no health disadvantage in persons with PTS. Our study revealed an increased mortality for patients with VLU and DVT. Even after adjustment for embolic events and infections of the venous ulcers mortality remained significantly higher.

BackgroundThis study applied a data-driven approach to explore whether being born during or around World War II affects the risk of morbidity later in life.MethodsIncident diagnoses were explored for diabetes (ICD-10 code E10-E14; 75,487 persons/12,905 incident cases), cerebrovascular disease (CeVD; I6; 79,829/11,664), and coronary heart disease (CHD; I20-I25; 89,657/11,116) for birth cohorts 1935-1950, using German health-claims data from 2004-2015. The data include quarterly information of the inpatient and outpatient treatment. We applied recursive partitioning methods with the aim of splitting the sample into birth cohorts with different risk profiles in terms of the incidence of diabetes, CeVD, and CHD. We performed Cox proportional hazard models to explore the transition into diabetes, CeVD, and CHD, accounting for birth cohort and gender. We used the median cut-points from the recursive partitioning analysis on the birth cohort indicator to define linear splines and present the yearly slopes of the linear splines.ResultsBased on the results from recursive partitioning method we defined four groups of birth cohorts depending on the disease of interest (diabetes: 1/35-10/37, 11/37-11/41, 12/41-10/44, 11/44-12/50; CHD: 1/35-5/37, 6/37-4/41, 10/44-12/50; CeVD: 1/35-6/37, 7/37-6/40, 7/40-12/43, 1/44-12/50). We found a general decline in cohort incidence for all three diseases, however, there was a discontinuation for diabetes among birth cohorts 12/41-10/44 (yearly slope=-0.01, p=0.584), and a deceleration for cohorts 11/44-12/50 for CeVD.ConclusionsWe identified risk periods associated with WWII that interfered with the cohort decline in the risk of diabetes and CeVD, stressing the importance of a beneficial early-life environment.Availability of dataThe scientific research institute of the AOK (WIdO) has strict rules regarding data sharing because of the fact that health claims data are a sensible data source and have ethical restrictions imposed due to concerns regarding privacy. Anonymized data are available to all interested researchers upon request. Interested individuals or an institution who wish to request access to the health claims data of the AOK, please contact the WIdO (webpage: http://www.wido.de/, mail: wido@wido.bv.aok.de).

We assessed the prevalence of morbidity in long-lived individuals according to age and age at death and explored the association between dementia and other diseases and surviving to age 90 and 100. Using health claims data from the largest German health insurer from 2004 to 2013, we followed birth cohorts from 1908 to 1913 from age 95 until death or survival to age 100 (n=2,865) and compared them with birth cohorts from 1918 to 1923 and their survival from age 85 to age 90 (n=17,013). We observed their exact date of death and main categories of morbidity based on International Classification of Diseases, Tenth Revision, diagnoses. For all diseases studied, when differentiated according to age at death, prevalence continued to increase with age. Nonagenarians and centenarians had significantly lower disease prevalence at each age. Dementia was associated with the highest risk of dying before becoming a centenarian (hazard ratio (HR)=1.63, 95% confidence interval (CI)=1.50-1.78), followed closely by the residual category other chronic heart disease (HR=1.42, 95% CI=1.30-1.56). Results were even stronger for the younger cohort. Our study shows that exceptionally long-lived individuals are different in terms of good health. Survival at these high ages depends primarily on the absence of dementia and chronic heart disease, with acute heart disease and pneumonia playing important roles as diseases leading directly to death.

Supplemental digital content is available in the text., Objective This study investigates the feasibility, reliability, and correlations of recommended functional tests in lung transplant recipients shortly after surgery. Design This is an observational study. Methods Fifty patients (28 females) performed well-standardized maximum isometric back extension in a sitting position, handgrip strength, and Biering-Sørensen endurance tests shortly before discharge from the acute hospital, shortly thereafter, and 2 mos later after subacute rehabilitation. Results Back extension testing was well feasible, but only two thirds of the patients could perform the Biering-Sørensen test at baseline and they experienced a greater number of minor but no major adverse events. Absolute reliability measures and the intraclass correlation coefficients were excellent for the strength (0.97–0.98 [0.95–0.99]) and good for the endurance tests (0.69 [0.26–0.87]). Handgrip revealed high correlation with back strength (≥0.75) but not with Biering-Sørensen scores. Conclusions Well-controlled maximum back strength testing is feasible and reliable, and the scores are highly correlated with grip strength in lung transplant recipients shortly before hospital discharge. The Biering-Sørensen test should be limited to patients without dominant weakness and/or fear. Future research should investigate whether grip instead of back extension strength can safely be used for proper exercise prescription.

We have read with interest the recent publication of Perez-Pardo and colleagues1 reporting the role of the TLR4 in the gut–brain axis in Parkinson’s disease (PD). These findings prompted us to investigate the role of common GI infections (GIIs) in the pathogenesis of PD. In this prospective cohort study, we assessed the risk of PD in patients who previously suffered from GIIs compared with the control group not exposed to GIIs (table 1). At study entry (1 January 2005), the analysis sample from health claims data of the largest German health insurer consisted of2 28 485 individuals aged 50 years and older, which were followed for a mean time of 8.6 years (median=11.0 years; IQR=7.6 years). PD and GIIs were defined by ICD-10 codes as described in the supplementary material. Overall, 6195 individuals (2.7%) developed PD and 50 492 individuals (22.1%) were affected by any GII during the observation period between 2005 and 2015. The most frequent GIIs were those that caused infectious gastroenteritis and colitis of unspecified origin (IGCUs; 39 093 individuals, 17.1%), followed by viral intestinal infections (VIIs; 9328 individuals, 4.1%) and bacterial intestinal infections (BIIs; 9298 individuals, 4.1%). The cumulative incidence of PD was significantly higher among individuals with GIIs (p

BACKGROUND: Exposure to fine particulate matter and black carbon is related to cognitive impairment and poor lung function, but less is known about the routes taken by different types of air pollutants to affect cognition.OBJECTIVES: We tested two possible routes of fine particulate matter (PM2.5) and black carbon (BC) in impairing cognition, and evaluated their importance: a direct route over the olfactory nerve or the blood stream, and an indirect route over the lung.METHODS: We used longitudinal observational data for 49,705 people aged 18+ from 2006 to 2015 from the Dutch Lifelines cohort study. By linking current home addresses to air pollution exposure data from ELAPSE in 2010, long-term average exposure to PM2.5 and BC was assessed. Lung function was measured by spirometry and Global Initiative (GLI) z-scores of forced expiratory volume in 1s (FEV1) and forced vital capacity (FVC) were calculated. Cognitive performance was measured by cognitive processing time (CPT) assessed by the Cogstate Brief Battery. Linear structural equation modeling was performed to test direct/indirect associations.RESULTS: Higher exposure to PM2.5 but not BC was related to higher CPT and slower cognitive processing speed [Total Effect PM2.5: FEV1 model = 8.31 × 10-3 (95% CI: 5.71 × 10-3, 10.91 × 10-3), FVC model = 8.30 × 10-3 (95% CI: 5.69 × 10-3, 10.90 × 10-3)]. The direct association of PM2.5 constituted more than 97% of the total effect. Mediation by lung function was low for PM2.5 with a mediated proportion of 1.32% (FEV1) and 2.05% (FVC), but higher for BC (7.01% and 13.82% respectively).DISCUSSION: Our results emphasise the importance of the lung acting as a mediator in the relationship between both exposure to PM2.5 and BC, and cognitive performance. However, higher exposure to PM2.5 was mainly directly associated with worse cognitive performance, which emphasises the health-relevance of fine particles due to their ability to reach vital organs directly.

Both developed and developing countries are facing economic and social challenges posed by an aging population. Dementia is one of the most common diseases in old age and has major consequences for society. In 2013, an estimated 44.4 million people worldwide suffered from dementia, and this number is expected to increase to 135.5 million by 2050. The current worldwide costs of dementia have been estimated at $604 billion, primarily due to the high demand for care. There is no known cure for dementia; however, positive developments with respect to lifestyle and recognizing risk factors in young and middle ages might have positive long-term effects on the risk of dementia in old age. Prevention and adequate medical treatment of these risk factors might help postpone dementia into higher ages. In addition, assistive technologies may help to mitigate the family and caregiver burden.

In the second half of the nineteenth century, mortality started to decline and this decline seemed to follow a cohort pattern. A cohort pattern is direct evidence for the effect of early-life circumstances on adult mortality: improvements in the living environment early in life lead to reduced mortality during the whole life course. Early studies for England, Wales and Scotland (Kermack et al. 1934, 2001) suggest that, as far as mortality up to the year 1925 is concerned, the year of birth had more predictive power than the year of death. Around 1925, the responsible factors for the mortality decline changed and the year of birth lost its predictive power. Period factors became more and more important. In a recent study, Davey Smith and Kuh (2001) updated the table of relative death rates for England and Wales from the Kermack paper. They showed that from 1925 onwards at younger ages, death rates fell faster than predicted based on birth cohort regularities, whereas at older ages, mortality declined at a much slower rate than predicted.

Background In Germany, epidemiological information on Parkinson's disease (PD) is rare and outdated. Considering aging populations, current prevalences and incidence rates about this age-related disease would be important for adequate public health planning. Methods We used newly available health claims data sets from the largest German health insurer dating 2004-2007 and 2007-2010 with an analysis population in the base years of 491 038 persons aged 50 and older. Quarter-specific information about ICD-10 diagnoses and PD drug prescriptions from the inpatient and outpatient sectors was used to validate PD cases. Estimations were presented for two validation strategies relying on repeated PD diagnoses (SIa) and on one PD diagnosis followed by at least one PD drug prescription (SIb). Results The standardized prevalence was 797 (SIb) to 961/100 000 persons (SIa), showing an age-specific increase up to category 85-89 and a decline thereafter. The standardized incidence rate was 192 to 229/100 000 person-years with a similar age-specific shape. Prevalences and incidences rates were higher for men compared to women in regard to age. Conclusions Health claims data are found to be suitable for PD assessment using the repeated diagnoses or PD drug prescriptions as necessary criteria.

The aims of the study were to classify impairments in postural control using computerized posturography in lung transplant recipients undergoing subacute rehabilitation and to examine the retest reliability of these measures.In a prospective repeated-measures study, 50 lung transplant recipients underwent clinical and quantitative posturographic testing (SMART EquiTest), which included the sensory organization test, motor control test, and limits of stability test. Testing was repeated after 1 to 2 days and upon completion of rehabilitation, 2 mos later. Main outcome measures were the following: sensory organization test-composite score, motor control test-latency and amplitude scaling, limits of stability test-movement velocity, and endpoint excursion/maximum excursion.At the beginning of rehabilitation, the mean sensory organization test-composite score and limits of stability test, but not the motor control test scores, were below normative reference values and and did not return to normal after rehabilitation. Intraclass correlation coefficients(2,1) yielded excellent relative reliability for all posturographic tests. The smallest detectable differences observed for the sensory organization test and limits of stability test exceeded the mean changes observed upon completion of rehabilitation.Impairments in sensory and anticipatory postural control were insufficiently restored after subacute lung transplantation rehabilitation. The little sensitivity of the sensory organization test-composite score or limits of stability test scores to detect a minimal change in performance due to rehabilitation limits the clinical applicability of these tests as objective outcome measures in lung transplantation rehabilitation.

Background Transcatheter aortic valve implantation (TAVI) is a minimally invasive treatment for aortic valve patients who are inoperable or have a prohibitively high surgical risk for surgical aortic valve replacement (SAVR). Most studies compare the efficacy of TAVI and SAVR, yet the assessment of TAVI for this group of patients requires more study. Methods This quasiexperimental study compares TAVI cases (ages of 75–90 years, n=187) ex-post with a control group without implantation (n=728, 4:1 ratio intended). The control group was drawn randomly on the condition that it matches the TAVI cases based on age at aortic valve disease incidence, gender and comorbidity index. The mortality risk is analysed from incident diagnosis. Data were taken from three random samples of health claims data in Germany’s largest public health insurance (Allgemeine Ortskrankenkassen) and cover the years 2004–2013 (n=750 000). Results Compared with the medically treated control group with 6+ comorbidities, medically treated patients with fewer comorbidities have half the mortality risk (HR 0.48, 95% CI 0.34 to 0.69, p

Background Behavioral and psychological symptoms of dementia are commonly treated with antipsychotic drugs (APDs), which have been associated with adverse health effects. We examine the effect of APDs on long-term care (LTC), nursing home (NH) admission, and death of dementia patients. Methods We used health claims data of the largest German health insurer from 2004 to 2010 and followed newly-diagnosed dementia patients aged 60 years and older into LTC, NH, and until death. Cox proportional hazards models were estimated to explore whether the risk of these outcomes differed between patients receiving haloperidol, melperone, risperidone, or quetiapine. Results In a cohort of 6,930 dementia patients who were initially free of LTC dependency, APD users generally faced a twofold increased risk of LTC relative to nonusers. Quetiapine was the exception, showing a comparatively lower risk (HR = 1.64; CI = 1.35–1.98). Among 9,950 dementia patients initially living in private homes, the risk of moving into a NH was generally increased by about 50% among APD users relative to nonusers. Risk of death (N = 10,921) was significantly higher for haloperidol-, melperone-, and risperidone- but not for quetiapine users (HR = 0.91; CI = 0.78–1.08). The excess mortality associated with haloperidol and melperone was greater among patients living in private households. Conclusions In our study, APDs appeared to accelerate adverse health outcomes in German dementia patients. Differentiating between the effect of antipsychotic drug use among dementia patients residing in private households and in NHs, we found that excess mortality for haloperidol and melperone users was higher in private settings.

Background:Cognitive decline is an important complication of joint replacement surgeries in senior people.Methods:We determined incidence rates of dementia diagnosis following endoprosthetic joint replacement surgery (upper and lower extremities). The observation period covered up to 28 quarters using German claims data comprising 154,604 cases 65 years and older. Effects were controlled for cerebrovascular and vascular risk factors, age, sex, the presence of a diagnosis of delirium, and regular prescription of sedative or analgesic drugs (SAD).Results:The rate of incident dementia diagnoses in people without joint replacement surgery was 21.34 per 1,000 person years, compared with 80.76 incident cases when joint replacement surgery was conducted during the quarter of the incident dementia diagnosis; rates declined to 21.77 incident cases 7 and more quarters after joint replacement surgery had taken place. This pattern was maintained when controlling for delirium diagnosis and regular prescription of SAD. Among 10,563 patients with at least one joint replacement surgery, patients with a diagnosis of delirium in the quarter of the surgery were at increased risk of a dementia diagnosis compared to patients without such a diagnosis (HR=2.00, p < 0.001).Conclusion:In people surviving the high-risk phase for dementia immediately after surgery, long-term risk of dementia may reach the level of those without surgery. These findings encourage consequent perioperative management to reduce the risk of dementia as well as prospective studies of potentially beneficial effects of joint replacement surgery on mid- to long-term recovery of mobility and cognition in geriatric patients.

The goal of this study was to assess the adherence of primary open-angle glaucoma (POAG) patients to medication, and to determine co-factors influencing adherence, using a representative sample of members of the largest German public health insurer. The observational cohort study was based on a longitudinal data set from 2010-2013 and included 250,000 insured persons aged 50 and older with 10,120 diagnosed POAG patients. Uni- and multivariate analysis was performed to investigate several aspects of glaucoma, such as prevalence, adherence, and co-factors influencing adherence. The main outcome measured adherence with prescriptions filled within a year. Multivariate panel regression analysis was used to determine the co-factors influencing this adherence. Prevalence of POAG was 3.36% [CI: 3.28-3.43%], with 2.91% [CI: 2.81-3.01%] for males and 3.71% [CI: 3.61-3.81%] for females, increasing with age. The mean level of adherence in terms of prescriptions filled was 66.5% [CI: 65.50-67.60%]. The results of this analysis revealed a significant influence of age, duration of the disease, care need, distance to death, and multimorbidity as co-factors of non-adherence, whereas gender had no influence. The analysis provided detailed information about POAG health care aspects concerning prevalence and adherence. The most endangered risk groups for non-adherence were patients aged 50-59, patients older than 80 years, patients with a longer duration of POAG, patients with care needs, and patients with three or more severe diseases in addition to glaucoma. To know the predictors responsible for an increased risk to develop POAG is of importance for all persons involved in health care management. Therefore effective strategies to increase awareness of patients and medical care personnel about non-adherence and the importance of a regular and continuous medication to avoid further nerve fiber damage and possible blindness have to be developed.

Demenzen sind einer der haufigsten Erkrankungen im Alter mit hohen Kosten fur die Gesellschaft. Wahrend in der Demenzforschung vaskulare Risikofaktoren im mittleren Lebensabschnitt im Vordergrund stehen, weitet dieser Beitrag den Blick auf die Lebensphase um den Zeitpunkt der Geburt aus. Wir stellen kurz die Theorien der metabolischen Programmierung des Fotus durch Umwelteinflusse (fetal programming), des Missverhaltnisses von Umwelteinflussen wahrend der Entwicklung des Fotus und der ersten Lebensjahre (thrifty phenotype) sowie der Lebenslaufepidemiologie vor. Unsere eigene empirische Studie beruht auf dem Geburtsmonat, einem exogenen Indikator fruher Lebensumstande. Wir besprechen den theoretischen Hintergrund dieses Indikators sowie Forschungsergebnisse zu weiteren exogenen Indikatoren wie Hungersnote, Epidemien und makro-okonomische Fluktuationen. Auf Basis von Daten der grosten gesetzlichen Krankenversicherung in Deutschland finden wir ein signifikant niedrigeres Demenzrisiko fur die im Winter Geborenen. Wir diskutieren Vor – und Nachteile von Abrechnungsdaten fur die Demenzforschung und prasentieren Forschungsergebnisse zu biologischen Mechanismen, die den von uns gefundenen Zusammenhang erklaren konnen.

A beam optics scheme has been designed for the Future Circular Collider-e+e- (FCC-ee). The main characteristics of the design are: beam energy 45 to 175 GeV, 100 km circumference with two interaction points (IPs) per ring, horizontal crossing angle of 30 mrad at the IP and the crab-waist scheme [1] with local chromaticity correction. The crab-waist scheme is implemented within the local chromaticity correction system without additional sextupoles, by reducing the strength of one of the two sextupoles for vertical chromatic correction at each side of the IP. So-called "tapering" of the magnets is applied, which scales all fields of the magnets according to the local beam energy to compensate for the effect of synchrotron radiation (SR) loss along the ring. An asymmetric layout near the interaction region reduces the critical energy of SR photons on the incoming side of the IP to values below 100 keV, while matching the geometry to the beam line of the FCC proton collider (FCC-hh) [2] as closely as possible. Sufficient transverse/longitudinal dynamic aperture (DA) has been obtained, including major dynamical effects, to assure an adequate beam lifetime in the presence of beamstrahlung and top-up injection. In particular, a momentum acceptance larger than +/-2% has been obtained, which is better than the momentum acceptance of typical collider rings by about a factor of 2. The effects of the detector solenoids including their compensation elements are taken into account as well as synchrotron radiation in all magnets. The optics presented in this paper is a step toward a full conceptual design for the collider. A number of issues have been identified for further study.

Importance Medications that influence the risk of dementia in the elderly can be relevant for dementia prevention. Proton pump inhibitors (PPIs) are widely used for the treatment of gastrointestinal diseases but have also been shown to be potentially involved in cognitive decline. Objective To examine the association between the use of PPIs and the risk of incident dementia in the elderly. Design, setting, and participants We conducted a prospective cohort study using observational data from 2004 to 2011, derived from the largest German statutory health insurer, Allgemeine Ortskrankenkassen (AOK). Data on inpatient and outpatient diagnoses (coded by the German modification of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision) and drug prescriptions (categorized according to the Anatomical Therapeutic Chemical Classification System) were available on a quarterly basis. Data analysis was performed from August to November 2015. Exposures Prescription of omeprazole, pantoprazole, lansoprazole, esomeprazole, or rabeprazole. Main outcomes and measures The main outcome was a diagnosis of incident dementia coded by the German modification of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. The association between PPI use and dementia was analyzed using time-dependent Cox regression. The model was adjusted for potential confounding factors, including age, sex, comorbidities, and polypharmacy. Results A total of 73,679 participants 75 years of age or older and free of dementia at baseline were analyzed. The patients receiving regular PPI medication (n = 2950; mean [SD] age, 83.8 [5.4] years; 77.9% female) had a significantly increased risk of incident dementia compared with the patients not receiving PPI medication (n = 70,729; mean [SD] age, 83.0 [5.6] years; 73.6% female) (hazard ratio, 1.44 [95% CI, 1.36-1.52]; P Conclusions and relevance The avoidance of PPI medication may prevent the development of dementia. This finding is supported by recent pharmacoepidemiological analyses on primary data and is in line with mouse models in which the use of PPIs increased the levels of β-amyloid in the brains of mice. Randomized, prospective clinical trials are needed to examine this connection in more detail.

Background Extremity injuries (EI) and dementia are important causes of long-term care (LTC), but they can also cause each other and are often present concurrently. Mobility-limiting EI can increase the risk of dementia, and dementia increases the risk for falls, which are often the cause of EI. When EI and dementia are present together, they can increase their negative effect on long-term care risk. This study aims to assess the strength of this interaction and the role of different body regions and severities of EI regarding LTC risk. Methods We use Cox proportional-hazard models on LTC as dependent variable. EI (primarily fractures) and dementia (all types) are the central independent variables. We control for age, sex, rehabilitation and 18 relevant comorbidities. Analyses are based on health claims records for 2004–2010 for a random sample of about 122.000 insurants of Germany's largest public health insurance "AOK" aged 65+, about 25.000 of whom entered LTC. Results Without concurrent dementia, non-severe EI (NSEI) of the lower and both extremities and all kinds of severe EI (SEI) increase LTC risk (HR: hazard ratio with 95% confidence interval. Lower NSEI: HR = 1.09 [1.05–1.14]; both NSEI: HR = 1.36 [1.29–1.44]. Lower SEI: HR = 1.67 [1.57–1.79]; upper SEI: HR = 1.27 [1.19–1.37]; both SEI: HR = 1.94 [1.81–2.07]). Dementia alone increases LTC risk more than fourfold (HR = 4.23 [4.11–4.35]). Taking the interaction of EI and dementia into account, the concurrent presence of EI and dementia tends to increase the LTC risk more than expected for lower as well as upper NSEI and SEI. Summarily, when lower or upper EI and dementia are both present, the LTC risk tends to be higher than expected, suggesting synergistic effects. Conclusions EI and dementia are important independent risk factors for long-term care. When lower or upper EI and dementia are present together, the resulting long-term care risk is increased disproportionately. Since the concurrent presence of both conditions increases the risk for care need, and a working treatment for dementia is not in sight, preventing EI, lessening the impact of EI and improving the outlook after an EI could help to reduce LTC need in the coming decades.

Recent research has revealed an association between hearing impairment and dementia. The objective of this study is to determine the effect of hearing impairment on dementia incidence in a longitudinal study, and whether ear, nose, and throat (ENT) specialist care, care level, institutionalization, or depression mediates or moderates this pathway. The present study used a longitudinal sample of 154,783 persons aged 65 and older from claims data of the largest German health insurer; containing 14,602 incident dementia diagnoses between 2006 and 2010. Dementia and hearing impairment diagnoses were defined according to International Classification of Diseases, Tenth Revision, codes. We used a Kaplan Meier estimator and performed Cox proportional hazard models to explore the effect of hearing impairment on dementia incidence, controlling for ENT specialist care, care level, institutionalization, and depression. Gender, age, and comorbidities were controlled for as potential confounders. Patients with bilateral (HR = 1.43, p

Background: Movement disorders are chronic diseases with an increasing prevalence in old age. Because these disorders pose a major challenge to patients, families, and health care systems, there is a need for reliable data about the future number of affected people. Patients and Methods: We searched the literature to identify epidemiological studies to obtain age-specific prevalence data of movement disorders. We combined the age-specific prevalence data with population projections for Europe, the United States, and Canada. Results: Movement disorders will increase considerably between 2010 and 2050. The highest increase will be for dementia with Lewy bodies. In several countries, we project a near doubling of patients with PD. Conclusions: There will be a strong increase in the number of people affected by most movement disorders between 2010 and 2050. This increase will mostly depend on the future aging of populations in terms of their age structure and future life expectancy. © 2011 Movement Disorder Society

Objective To assess factors associated with diabetic retinopathy (DR) screening uptake following a diagnosis of type 2 diabetes mellitus (type 2 diabetes) in Germany. Materials and methods A nationally representative prospective sample of individual-level health claims data for 250,000 members from Germany's largest public insurance provider in 2004-2013 was assessed. In the sample, 26,560 persons with incident type 2 diabetes were identified. Factors associated with subsequent DR screening were assessed using descriptive statistics, Kaplan-Meier estimator, and Cox regression analysis. Results On average 27.6 visits to an ophthalmologist per 100 person-years in persons with incident type 2 diabetes occurred. Half of all incident cases (Kaplan-Meier estimator) had not seen an ophthalmologist after more than two years (2.25 years) following their diabetes diagnosis. In the multivariate analysis, an older age (from hazard ratio HR(70-74) = 0.93 [95%-CI: 0.89-0.97] to HR(90+) = 0.50 [95%-CI: 0.42-0.60] compared to persons aged 50-69 years) and a higher disability level (i.e. HR(disability level 3) = 0.30 [95%-CI: 0.25-0.36]) were associated with a lower likelihood, while female sex (HR = 1.12 [95%-CI: 1.08-1.15]), six or more comorbidities (HR = 1.26 [95%-CI: 1.15-1.37]), moderate (HR = 1.51 [95%-CI: 1.46-1.56]) or severe type 2 diabetes (HR = 1.53 [95%-CI: 1.45-1.61]) as well as being enrolled in a type 2 diabetes disease management program (HR = 1.78 [95%-CI: 1.69-1.87]) were associated with a higher likelihood of DR screening. Conclusions A high proportion of newly diagnosed persons with type 2 diabetes did not follow current German recommendations for DR screening, impeding timely detection and management of potential complications. This was more apparent among persons who were men, older or had a disability. The uptake of screening was considerably greater among those enrolled in a diseases management program. These factors need to be considered when planning DR screening services and/or referrals.

So far all calculations of the number of demented people are based on rates from meta-analyses, mean rates of meta-analyses or spatial analyses. This article presents age- and gender-specific prevalence and incidence rates of dementia that are based on a large sample of the German Sick Funds (Stichprobendaten von Versicherten der gesetzlichen Krankenversicherung (GKV)) with 2.3 million people from the year 2002. Prevalence rates increase from 0.8% and 0.6% for 60-64 year old men and women to 30% and 43% for men and women aged 100 or older, respectively. Incidence rates increase from 0.18 and 0.14 cases per 100 person-years for 60-64-year old men and women to 9.9 and 10.9 for over 95 year old men and women, respectively. Our results confirm rates from earlier studies on the basis of meta-analyses. Regional differences show for the first time that higher prevalence rates exist for East German women and men above age 85. In 2007 about 1.07 million moderately or severely demented people live in Germany of which about 244 000 are incident cases when we extrapolate our rates to the population of this year.

The 11th coordinated population forecast of the German Federal Statistical Office shows that the number of children in the age group 0-15 is going to decrease considerably up to 2050. Depending on the assumptions, the number of children will decrease to 50-80% of today's level. There are only small regional differences in this development, i. e., all regions will be equally affected by the population decline. However, large cities and surrounding areas will face smaller reductions than other community types. The timing of the decline differs somewhat between the regions. An exception is the age group 10-15 in East Germany. After a strong reduction of births in the years after the reunification, birth rates have been rising since 1998, which will lead to a relative increase of that age group in the coming years. However, also in this age group, the number of children is going to decrease to 85% of today's level up to 2050. In parallel to the reductions in the young population, there will be a reduction in the frequency of diagnoses, whereby in a simplified "status quo" model, the amount of diagnoses will decrease in proportion to the number of the 0-15-year-olds.

In Germany, the share of the older population has been continuously growing. Is the increase paralleled by a rising number of frail people, however? In search of an answer, we analyse the development of care need incidence in West Germany between 1986 and 2005 on the basis of longitudinal data from the German Socio-Economic Panel (SOEP). The results show a lower transition risk to care need for each successive cohort when all degrees of care need are taken into account. However, no change occurs when only severe care need is measured.

This article uses census records and deaths records to analyze trends in educational inequalities in mortality for Austrian women and men aged 35–64 years between 1981/1982 and 1991/1992. We find an increasing gradient in mortality by education for circulatory diseases and especially ischaemic heart disease. Respiratory diseases and, in addition for women, cancers showed the opposite trend. Using decomposition analysis, we give evidence that in many cases changes in the age-structure within the 10-year interval had a bigger effect than direct improvements in mortality on the analyzed subpopulations.

The examination of AGI agents is an interdisciplinary challenge. This is particularly the case for their foundations, assumedly (in compliance with Damasio) drives and emotions. We demonstrate how these foundations of a human-like control system are tested using simplified exemplary cases as test-specifications. After showing how we model the required functions of the agent's decision unit, we provide details of the incremental steps of our examination. As a first step, we use calibration-specifications, which we concretize with the help of psychoanalysts and neuroscientists and show how a flexible parameterization of the model generates expected behavior. This step enables a deeper model analysis in the second step of our examination, which corresponds to model exploration and provides further information for adaptions of the parameters, model, or assumptions. Overall, this examination methodology allows for a stepwise model development and examination and provides the ground for comparing the simulation data with empirical data, which we plan as a next step.

As the population ages, the numbers of people developing care- and cost-intensive forms of dementia are raising. We investigated the pathways of incident dementia patients to long-term care (LTC) dependence and death, and examined the effects of: (1) the type of the main treating physician, differentiated by neurologists/psychiatrists (NPs) and non-NPs; (2) the prescription of antidementive drugs on the risk of needing LTC, differentiated by the degree of care need. Longitudinal claims data of the largest German public sickness fund of 10,043 incident dementia cases aged 60 years and above were analyzed for the years 2006 to 2010. Cox proportional hazard models were performed to investigate the risk of LTC and death based on what type of physician was treating the patient, and whether the patient was prescribed antidementive drugs; adjusted for age, gender, cardiovascular comorbidities, and the previous LTC level. The patients who were primarily treated by NPs had a significantly lower risk of LTC than patients who were mainly treated by non-NPs (considerable LTC: RR = 0.72, p = 0.000, severe LTC: RR = 0.78, p = 0.000, extreme LTC: RR = 0.67, p = 0.001). They generally had a lower risk of death. Antidementive drug treatment was correlated with an increased risk of LTC (considerable LTC: RR = 1.66, p = 0.000, severe LTC: RR = 1.50, p = 0.000, extreme LTC: RR = 1.48, p = 0.000) but with a decreased risk of death. A higher rate of involvement of specialists in the treatment of dementia patients is associated with a reduced LTC dependence and increased survival of dementia patients. Antidementive drug treatments appear to extend live years with dementia.

Objectives To determine the association between hearing impairment and dementia. Design Cross-sectional study. Setting Claims data of the Allgemeine Ortskrankenkasse, the largest public health insurance company in Germany. Participants Age-stratified sample of all insured persons aged 65 and above in the first quarter of 2007 (N = 1,338,462). Measurements Metaregression analysis on the association between regional prevalence of dementia and hearing impairment controlled for major vascular risk factors, including hypertension, hypercholesterolemia, diabetes mellitus, and cerebrovascular disease. Dementia and hearing impairment diagnoses were defined according to International Classification of Diseases, Tenth Revision, codes. Ninety-five regions were distinguished according to the two-digit postal code of the place of residence. Results A significant association was found between regional prevalences of dementia and hearing impairment that was preserved when controlling for major vascular risk factors (P = .003). Regional dementia prevalence increased by approximately 0.23% when the prevalence of hearing impairment increased by 1 standard deviation. Conclusion The relationship between hearing impairment and dementia has been repeatedly demonstrated on the individual level. The results of the current study confirm that this relationship also exists on a regional level. These findings underscore the potential role of hearing impairment as a risk factor for dementia that will be relevant for the management of elderly patients in general practice.

In allen industrialisierten Landern leben Frauen langer als Manner und machen daher einen Grosteil der alten Bevolkerung aus. Die Ursachen dafur liegen in biologischen und sozialen Faktoren, in Deutschland auch in der jungeren Vergangenheit. Niedrige Kinderzahlen und steigende Lebenserwartung fuhren zur Alterung der deutschen Bevolkerung mit einer starken Zunahme der Alten und Hochaltrigen. Die zukunftigen Alten werden gesunder, besser ausgebildet und zu einem hoheren Anteil verheiratet sein, sie werden mehr Kinder haben. Die Zahl der Pflegedurftigen wird ansteigen, Bevolkerungsgruppen mit hohem Risiko, auf institutionelle Pflege angewiesen zu sein, werden am wenigsten stark wachsen.