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OBJECTIVES There is a lack of studies identifying the correlates of institutionalization specifically among the oldest old. Therefore, our aim was to fill this gap in knowledge. METHODS Cross-sectional data (Follow up wave 9; n = 633 observations in the analytical sample) were used from the multicenter prospective cohort study "Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" Correlates of institutionalization among the oldest old-Evidence from a multicenter cohort study. The sample consists of primary care patients aged 86 years and over (mean 90.5 years, SD: 2.9 years). Sociodemographic and health-related independent variables were included in our regression model. Institutionalization was defined as living in a nursing home or an old-age home (not including assisted living facilities). RESULTS Out of the 633 participants, 502 individuals (79.3%) did not live in an institutionalized setting, whereas 73 individuals (20.7%) lived in an institutionalized setting. Multiple logistic regressions showed that the likelihood of institutionalization increased with being divorced/widowed/single (compared to being married; OR: 5.35 [95% CI: 1.75-16.36]), the presence of social isolation (OR: 2.07 [1.20-3.59]), more depressive symptoms (OR: 1.11 [1.01-1.23]), increased cognitive impairment (OR: 1.67 [1.31-2.15]) and higher levels of frailty (OR: 1.48 [1.07-2.06]). CONCLUSION The study findings identified various sociodemographic and health-related factors associated with institutionalization among the oldest old. Longitudinal studies are required to gain further insights into these associations.

Zusammenfassung Zielsetzung In vorangegangenen Untersuchungen der KarMed-Studie konnte gezeigt werden, dass Arztinnen in facharztlicher Weiterbildung mit Kindern im Vergleich zu ihren mannlichen Kollegen langsschnittlich eine absinkende Berufsverlaufszufriedenheit aufweisen – querschnittlich nach vier Jahren Weiterbildung jedoch die hochsten Werte fur Lebenszufriedenheit aufwiesen. In der vorliegenden Studie sollte untersucht werden, ob die unterschiedlichen Verlaufe der Berufsverlaufs- und Lebenszufriedenheit durch den Elternstatus bedingt werden oder ob es sich, getrennt nach Geschlecht, umgekehrt verhalt. Methode Die Daten wurden jahrlich im Rahmen der Forschungsstudie KarMed erhoben (2008-2016; vgl. https://www.uke.de/kliniken-institute/institute/allgemeinmedizin/forschung/karriereverl%C3%A4ufe-von-%C3%A4rztinnen-und-%C3%A4rzten-w%C3%A4hrend-der-fach%C3%A4rztlichen-weiterbildung.html ). Abgebildet wird ein Langsschnitt zu den Befragungen im Zeitraum von zwei bis funf Jahren nach dem Praktischen Jahr (T2 bis T5). Zur longitudinalen Analyse wurden zeitverzogerte Pfadmodelle (cross-lagged panel design) berechnet. Ergebnisse Es findet sich ein inverser Zusammenhang zwischen der Berufsverlaufszufriedenheit und dem Elternstatus fur Arztinnen im Vergleich zu Arzten in facharztlicher Weiterbildung. Arztinnen mit einer niedrigen Berufsverlaufsverlaufszufriedenheit bekommen eher Kinder als Arztinnen mit einer hohen Berufsverlaufszufriedenheit; bei Arzten erhoht der Elternstatus kausal die Berufsverlaufszufriedenheit. Fur Arztinnen, nicht aber fur Arzte, sagt das Ausmas der Lebenszufriedenheit den Elternstatus vorher. Schlussfolgerung Die vorliegenden Ergebnisse weisen auf strukturelle Ungleichheiten zwischen Arzten und Arztinnen hin, die Anpassungen der Weiterbildungsbedingungen vor Beginn des Elternstatus dringend erforderlich erscheinen lassen. Zukunftige Studien sollten ein mutterschutzbedingtes partielles Beschaftigungsverbot sowie die von Arzten in Anspruch genommenen Elternzeiten mitberucksichtigen.

Background Depression in older adults is becoming an increasing concern. As depressive symptoms change over time, it is important to understand the determinants of change in depressive symptoms. The aim of our study is to use a longitudinal study design to explore the predictors of change, remission and incident depression in older patients with multimorbidity. Methods Data from the MultiCare cohort study were used. The cohort studied 3,189 multimorbid general practice patients aged 65-85. Data were collected during personal interviews. Depressive symptoms were assessed using the Geriatric Depression Scale (GDS-15). Predictors of change in depressive symptoms were determined using multivariate linear regression, while multivariate logistic regression was used to analyze predictors of remission and incident depression. Models included depressive symptoms at baseline and follow-up, socio-demographics and data on health status and social support. Results Overall, 2,746 participants with complete follow-up data were analyzed. Mean age was 74.2 years, 59.2% were female, and 11.3% were classified as depressed at baseline. Burden of multimorbidity and social support were statistically significant predictors in all regression analyses. Further predictors of change in depressive symptoms were: income, pain, nursing grade, self-rated health and self-efficacy. Limitations The sample size for prediction of remission limited statistical certainty. Assessment of depressive symptoms using GDS-15 differs from routine clinical diagnoses of depression. Conclusions Predictors of change in depressive symptoms in older multimorbid patients are similar to those predicting remission and incident depression, and do not seem to differ significantly from other older patient populations with depressive symptoms.

Background The elderly population deals with multimorbidity (three chronic conditions) and increasinged drug use with age. A comprehensive characterisation of the medication – including prescription and over-the-counter (OTC) drugs – of elderly patients in primary care is still insufficient. Objectives This study aims to characterise the medication (prescription and OTC) of multimorbid elderly patients in primary care and living at home by identifying drug patterns to evaluate the relationship between drugs and drug groups and reveal associations with recently published multimorbidity clusters of the same cohort. Methods MultiCare was a multicentre, prospective, observational cohort study of 3189 multimorbid patients aged 65 to 85 years in primary care in Germany. Patients and general practitioners were interviewed between 2008 and 2009. Drug patterns were identified using exploratory factor analysis. The relations between the drug patterns with the three multimorbidity clusters were analysed with Spearman-Rank-Correlation. Results Patients (59.3% female) used in mean 7.7 drugs; in total 24,535 drugs (23.7% OTC) were detected. Five drug patterns for men (drugs for obstructive pulmonary diseases (D-OPD), drugs for coronary heart diseases and hypertension (D-CHD), drugs for osteoporosis (D-Osteo), drugs for heart failure and drugs for pain) and four drug patterns for women (D-Osteo, D-CHD, D-OPD and drugs for diuretics and gout) were detected. Significant associations between multimorbidity clusters and drug patterns were detectable (D-CHD and CMD: male: ρ = 0.376, CI 0.322–0.430; female: ρ = 0.301, CI 0.624–0.340). Conclusion The drug patterns demonstrate non-random relations in drug use in multimorbid elderly patients and systematic associations between drug patterns and multimorbidity clusters were found in primary care.

Objectives Previous studies have observed protective effects of high mental demands at work on cognitive functioning and dementia risk. However, it is unclear what types of demands drive this effect and whether this effect is subject to a person's genetic risk. We investigated to what extent eight different types of mental demands at work together with the APOE e4 allele, a major risk gene for late-onset Alzheimer's disease, affect cognitive functioning in late life. Methods/design The population-based German Study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe, n=2,154) followed cognitively healthy individuals aged 75 years and older in seven assessment waves. Cognitive functioning was assessed via the mini-mental status examination. Results Mixed-effects modeling (adjusted for education, gender, marital status, stroke, depression, and diabetes) indicated that participants who had an occupational history of working in jobs with high compared to low demands in 'Language & Knowledge', 'Pattern detection', 'Information processing', and 'Service' had a slower cognitive decline. APOE e4-allele carriers had an accelerated cognitive decline, but this decline was significantly smaller if they had a medium compared to a low level of demands in contrast to non-carriers. Conclusions Our longitudinal observations suggest that cognitive decline could be slowed by an intellectually enriched lifestyle even in risk gene carriers. Fostering intellectual engagement throughout the life-course could be a key prevention initiative to promote better cognitive health in old age. This article is protected by copyright. All rights reserved.

ZusammenfassungMehrere Studien belegen den hohen beruflichen Stress von Ärzten und Ärztinnen bis hin zu Burnout-Symptomen. Untersucht In der vorliegenden Studie wurde das Belastungserleben von Ärzten und Ärztinnen im längsschnittlichen Verlauf der fachärztlichen Weiterbildung untersucht. Dazu wurde der Frage nachgegangen, wie sich das Burnouterleben unter Berücksichtigung von Gratifikationskrisen von Beginn bis zum Ende der Weiterbildung an innerhalb von 6 Jahren verändert und ob es jeweils einen Einfluss von Geschlecht und Elternstatus gibt. Die Datenerhebung erfolgte im Rahmen der KarMed Studie. Eingesetzt wurden das Maslach Burnout Inventar (MBI-HSS (MP)) und der Effort-Reward-Imbalance Fragebogen (ERI). Die theoretischen Annahmen wurden in allgemeinen linearen Modellen und allgemeinen linearen gemischten Modellen mit Meßwiederholungsdesign statistisch überprüft. Es bestand ein hoher Zusammenhang zwischen dem Ausgangsniveau der Belastung zu Beginn der Weiterbildung und dem Belastungserleben zum Ende der Weiterbildung. Gratifikationskrisen hatten einen signifikanten Einfluss auf die Sub-Skala emotionale Erschöpfung des MBI, nicht aber auf die Subskalen persönliche Leistungsfähigkeit und Depersonalisation. Signifikante Zeiteffekte fanden sich auf allen 3 Sub-Skalen des MBI, mit signifikanten Geschlechtseffekten auf den Subskalen emotionale Erschöpfung und Depersonalistaion. Der Elternstatus weist unter Berücksichtigung der Burnout-Verlaufswerte und Gratifikationskrisen keinen signifikanten Einfluss auf das Burnouterleben auf. Die theoretischen Implikationen und die praktischen Konsequenzen für die Gesundheitsförderung von ÄrztInnen werden ebenso diskutiert wie die Begrenzungen der Untersuchung.

Introduction: Due to the strong association between old age and the need for long-term care, the number of individuals in need for care is projected to increase noticeably. The aim of this study was to examine the determinants of institutionalization among the oldest old longitudinally. Methods: Longitudinal data (follow-up [FU] wave 7–9) were gathered from a multicenter prospective cohort study (“Study on needs, health service use, costs and health-related quality of life in a large sample of oldest old primary care patients [85+],” AgeQualiDe). At FU wave 7, in 2014, complete measures were available for 763 individuals. The average age was 88.9 (standard deviation 2.9) years (range 85–100), and 68% were female. Sociodemographic and health-related independent variables (e.g., depressive symptoms or functioning) were included in the regression model. Institutionalization (admission to assisted living home or nursing home) was used as an outcome measure. Logistic random-effects models were used. Results: Regressions revealed that among oldest old, the odds of being institutionalized were lower for men (odds ratio [OR] = 0.03; 95% confidence interval [CI] 0.00–0.16). Institutionalization was associated with an increased age (OR = 1.27; 95% CI 1.04–1.55). Additionally, widowed individuals (ref. non-widowed) had higher odds of being institutionalized (OR = 8.95; 95% CI 1.61–49.81). Institutionalization was also associated with functional decline (OR = 0.16; 95% CI 0.11–0.23), whereas it was not significantly associated with cognitive decline, depressive symptoms, and social support. Conclusion: Our findings stress the importance of gender, age, widowhood, and functional decline for institutionalization among the oldest old. Preventing or at least postponing functional decline might help to delay institutionalization as far as possible.

Objectives:To examine the impact of determinants of incident dementia in three different old age groups (75–79, 80–84, 85+years) in Germany.Design:Multicenter prospective AgeCoDe/AgeQualiDe cohort study with baseline and nine follow-up assessments at 1.5-year intervals.Setting:Primary care medical record registry sample.Participants:General practitioners’ (GPs) patients aged 75+years at baseline.Measurements:Conduction of standardized interviews including neuropsychological assessment and collection of GP information at each assessment wave. We used age-stratified competing risk regression models (accounting for the competing event of mortality) to assess determinants of incident dementia and age-stratified ordinary least square regressions to quantify the impact of identified determinants on the age at dementia onset.Results:Among 3027 dementia-free GP patients,n= 704 (23.3%) developed dementia during the 13-year study period. Worse cognitive performance and subjective memory decline with related worries at baseline, and the APOE ε4 allele were associated independently with increased dementia risk in all three old age groups. Worse cognitive performance at baseline was also associated with younger age at dementia onset in all three age groups. Other well-known determinants were associated with dementia risk and age at dementia onset only in some or in none of the three old age groups.Conclusions:This study provides further evidence for the age-specific importance of determinants of incident dementia in old age. Such specifics have to be considered more strongly particularly with regard to potential approaches of early detection and prevention of dementia.

Zusammenfassung Zielsetzung In der vorliegenden Arbeit wurde im Langsschnitt untersucht, inwiefern die angenommene Verzogerung des Abschlusses und die subjektive Einschatzung der Qualitat der Weiterbildung mit einer Veranderung der Berufsverlaufszufriedenheit von Arzten und Arztinnen in der Facharztausbildung zusammenhangen. Methode Die untersuchten Daten wurden in der Forschungsstudie KarMed erhoben. Die erste Erhebung (T0) wurde 2008/2009 am Ende des Praktischen Jahres durchgefuhrt. Abgebildet wird ein Langsschnitt zur Befragung im Zeitraum von drei bis funf Jahren nach dem Praktischen Jahr (T3 bis T5). Zur longitudinalen Analyse wurden Hierarchisch Lineare Modelle und zeitverzogerte Pfadmodelle eingesetzt. Die Analysen wurden kontrolliert fur Geschlecht, Elternstatus und Fachdisziplin. Ergebnisse Pfadanalysen ergaben, dass eine positive Berufsverlaufszufriedenheit einen kleinen bis mittleren kausalen positiven Effekt auf die subjektiv wahrgenommene Qualitat der Weiterbildung hatte. Eine angenommene Verzogerung der Weiterbildung hatte einen kleinen signifikanten kausalen negativen Effekt auf die Berufsverlaufszufriedenheit und eine hohere Berufsverlaufszufriedenheit hatte einen kleinen signifikanten kausalen negativen Effekt auf die Verzogerung der Weiterbildung. Das Geschlecht sagte die Berufsverlaufszufriedenheit von Eltern mit Kindern vorher. Demnach sank die Zufriedenheit bei Arztinnen mit Kindern gegenuber Arzten mit Kindern im Verlauf der Weiterbildung signifikant ab. Die Fachdisziplin wies keinen signifikanten Effekt auf die Berufsverlaufszufriedenheit auf. Schlussfolgerung Wenn Arzte mit ihrem Beruf zufrieden sind, dann schatzen sie subjektiv auch die Qualitat der Weiterbildung positiver ein. Die angenommene Verzogerung der Weiterbildung und die Berufsverlaufszufriedenheit hangen reziprok miteinander zusammen. Die Bedarfslage zur Verbesserung der facharztlichen Weiterbildung scheint insbesondere bei Arztinnen mit Kindern gegeben zu sein.

ObjectiveSince there is a lack of longitudinal studies in this area, our aim was to identify the determinants of persistent frequent attendance in primary care among the oldest old in Germany.MethodsLongitudinal data (follow-up wave 7–9) were taken from the multicenter prospective cohort “Study on needs, health service use, costs, and health-related quality of life in a large sample of oldest-old primary care patients (85+)” (AgeQualiDe), covering primary care patients ≥ 85 years (FU7 n = 741, mean age 88.9 years (SD 2.9; 85–100)). Persistent frequent attenders of general practitioner (GP) services (the patients in the top decile of the number of GP consultations in two or more consecutive waves) were our main outcome of interest. Logistic random-effects models were used.ResultsOur analysis included 1,891 observations (766 individuals). Across three waves, we identified 56 persistent frequent attenders. Results of random-effects logistic regressions showed that the odds of being persistent frequent attender were higher for widowed individuals (OR = 4.57; 95% CI [1.07–19.45]). Moreover, a one-point increase in the frailty score and having one more chronic condition increased the odds of being a persistent frequent attender by 68% (OR =1.68; 95% CI [1.05–2.69]) and 23% (OR=1.23, 95% CI [1.05–1.44]), respectively.ConclusionOur study stressed the longitudinal association between frailty and widowhood as well as chronic diseases and persistent frequent attendance among the oldest old in Germany.

In Deutschland droht ein Nachwuchsmangel im hausarztlichen Bereich. Ein Drittel der aktuell tatigen Hausarztinnen und Hausarzte ist 60 Jahre und alter. Jahrlich verlassen 1700 Personen den Beruf, wahrend nur etwa 1350 neue facharztliche Anerkennungen ausgestellt werden. Der Sachverstandigenrat zur Begutachtung der Entwicklung im Gesundheitswesen (SVRG) geht von einem nicht gedeckten Ersatzbedarf von rund 20.000 Stellen bis 2025 aus. 2017 waren bereits 2600 hausarztliche Kassenarztsitze (KV-Sitze) nicht besetzt. Basierend auf den Ergebnissen der KarMed-Studie geht dieser Beitrag den Fragen nach, wie viele Arztinnen und Arzte in Weiterbildung eine spatere hausarztliche Tatigkeit anstreben, welche Vorstellungen damit einhergehen und welche Folgen der steigende Anteil von Arztinnen in der hausarztlichen Versorgung in Bezug auf das mogliche Arbeitsvolumen haben wird. Ferner werden Masnahmen diskutiert, die ein eventuelles personelles Defizit abmildern konnten. Die Attraktivitat der hausarztlichen Tatigkeit nahm bei Arztinnen uber die sechs Jahre betrachtlich zu. Zudem zeigt sich ein Zusammenhang zwischen der Praferenz fur hausarztliche Tatigkeit und Elternschaft. Arztinnen streben Teilzeittatigkeit und ein Angestelltenverhaltnis an. Aufgrund dessen und weiterer Faktoren kann geschatzt werden, dass sich das Arbeitsvolumen bei Hausarztinnen im Vergleich zum traditionellen Arbeitsmodell kunftig halbieren wird. Die prognostizierten Nachwuchszahlen durften keinesfalls ausreichen, um den Bedarf an hausarztlicher Versorgung in Deutschland zu decken. Mogliche wirksame Masnahmen waren u. a.: Einfuhrung eines Primararztsystems, Schaffung multiprofessioneller Zentren, Quotierung des Zugangs zur Spezialistenweiterbildung, Bedarfsplanung sowie Verkurzung und Flexibilisierung der allgemeinmedizinischen Weiterbildung.

The correct and early diagnosis of a rare disease in children is of particular importance in regard to the frequently fateful consequences for young families. Even well-known rare diseases are diagnosed with unacceptable delay in many countries. After decades of studying medical histories with delayed diagnoses and the respective literature, we describe the often severe aftereffects of a late diagnosis. We point out the underlying problems on the part of the physicians involved, of the affected families and of the health system in Germany, in particular with respect to the many emerging centers for rare diseases, most of which are associated with academic institutions. We gained the impression that the cause of delayed diagnoses is frequently not a lack of expertise or other resources, but inefficient communication between parents, practitioners and expert centers. We consider two approaches as promising and practicable: (1) strengthening the parents' competence and role in the dialogue with their doctors, an important element of which is obtaining written information on the state of the diagnostic process in language understandable to the parents; (2) definition of binding requirements for centers officially dedicated to the diagnosis of rare diseases and to research into unknown conditions. Many of our observations and deliberations in the pediatric field should be equally applicable to adults.

Background Low health literacy is believed to be associated with behaviours that increase the risk of type 2 diabetes. But there is limited knowledge on the relation between health literacy (HL) and diabetes risk, and whether improving HL could be a potential prevention strategy. Therefore, the main purpose of this study was to examine the link between HL and diabetes risk among non-diabetic adults. Methods We used data from the Hamburg Diabetes Prevention Survey, a population-based cross-sectional study in Germany. One thousand, two hundred and fifty-five non-diabetic subjects aged 18–60 years were eligible. The German Diabetes Risk Score (GDRS, ranging 0 to 123 points) was used to determine the individual risk of type 2 diabetes. The short version of the European Health Literacy Questionnaire (HLS-EU-Q16, ranging 0 to 16 points) was applied to assess the individual self-reported HL. Subjects were asked to self-estimate their diabetes risk, which was then compared with the calculated GDRS. Descriptive statistics were calculated to investigate group differences in the GDRS and self-estimated diabetes risk. Linear as well as logistic regression models were performed to analyse potential influencing variables of the GDRS as well as incorrect self-estimated diabetes risk. In three nested statistical models for each outcome, these analyses were adjusted for age, gender, educational level and the presence of chronic conditions. Results According to the criteria of the GDRS, 996 (79.4%) subjects showed “low risk”, 176 (14.0%) “still low risk”, 53 (4.2%) “elevated risk”, and 30 (2.4%) “high to very high risk” to develop type 2 diabetes within the next 5 years. In the statistical models including all control variables, subjects with “inadequate HL” scored 2.38 points higher on the GDRS (95% CI 0.378 to 4.336; P = 0.020) and had a 2.04 greater chance to estimate their diabetes risk incorrectly (OR 2.04; 95% CI 1.33 to 3.14; P = 0.001) compared to those with “sufficient HL”. Conclusion The risk of type 2 diabetes is increased in people with inadequate self-reported HL. People with high diabetes risk and inadequate HL might be provided with educational programs to improve diabetes knowledge and reduce behavioural risk factors.

This study aimed to examine the association of alcohol and tobacco use with severity of depression in older age. Analyses were performed on a pooled data set (n = 3724) from two German old-age cohort studies (LEILA 75+, 6 follow-ups and AgeCoDe/AgeQualiDe, 9 follow-ups). Depressive symptoms were assessed via two screening scales for depression (CES-D and GDS-15) which were harmonized for pooled analysis. A mixed-effects linear regression model for the total sample and additional stratified models for men and women were used. Smoking at baseline was significantly associated with a higher level of depression severity (β = 0.142, 95% CI: 0.051–0.233, p = 0.002), whereas drinking was significantly associated with a decreased level of depression (β = −0.069, 95% CI: −0.119–−0.021, p = 0.005). Concurrent substance use at baseline increased longitudinal depression severity (β = 0.193, 95% CI: 0.011–0.375, p = 0.037). Analyses stratified by gender showed a significant inverse association between drinking and depressive symptoms in men (β = −0.138, 95% CI: −0.231–−0.045, p = 0.004), but not in women (β = −0.060, 95% CI: −0.120–0.001, p = 0.052). Given the burden of major depression, it is important that health care providers, especially primary care physicians, assess and monitor lifestyle factors, even at older ages.

Research on anxiety in oldest-old individuals is scarce. Specifically, incidence studies based on large community samples are lacking. The objective of this study is to assess age- and gender-specific incidence rates in a large sample of oldest-old individuals and to identify potential risk factors. The study included data from N = 702 adults aged 81 to 97 years. Anxiety symptoms were identified using the short form of the Geriatric Anxiety Inventory (GAI-SF). Associations of potential risk factors with anxiety incidence were analyzed using Cox proportional hazard models. Out of the N = 702 older adults, N = 77 individuals developed anxiety symptoms during the follow-up period. The incidence rate was 51.3 (95% CI: 41.2–64.1) per 1000 person-years in the overall sample, compared to 58.5 (95% CI: 43.2–72.4) in women and 37.3 (95% CI: 23.6–58.3) in men. Multivariable analysis showed an association of subjective memory complaints (HR: 2.03, 95% CI: 1.16–3.57) and depressive symptoms (HR: 3.20, 95% CI: 1.46–7.01) with incident anxiety in the follow-up. Incident anxiety is highly common in late life. Depressive symptoms and subjective memory complaints are major risk factors of new episodes. Incident anxiety appears to be a response to subjective memory complaints independent of depressive symptoms.

Background It is almost unknown whether the driving status is associated with HRQOL among individuals in highest age. Aims Based on a multicenter prospective cohort study, the objective of this study was to examine whether the driving status is associated with health-related quality of life (HRQOL) among the oldest old in Germany. Methods Cross-sectional data from follow-up wave 9 (n = 544) were derived from the “Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)” (AgeQualiDe). Average age was 90.3 years (± 2.7; 86 to 101 years). The current driver status (no; yes) was used in our analysis. The EuroQoL EQ-5D questionnaire was used to assess HRQOL in this study. Results Regression analysis showed that being a current driver was associated with the absence of problems in ‘self-care’ [OR 0.41 (95%-CI 0.17 to 0.98)], and ‘usual activities’ [OR 0.48 (0.26 to 0.90)], whereas it was not significantly associated with problems in ‘pain/discomfort’ [OR 0.82 (0.47 to 1.45)] and ‘anxiety/depression’ [OR 0.71 (0.36 to 1.39)]. Being a current driver was marginally significantly associated with the absence of problems in ‘mobility’ [OR 0.60 (0.34 to 1.06)]. While being a current driver was not associated with the EQ-VAS in the main model, it was positively associated with the driving status (β = 5.00, p Discussion Our findings provide first evidence for an association between driving status and HRQOL among the oldest old. Conclusions Future longitudinal studies are required to evaluate a possible causal relationship between driving status and HRQOL in very old individuals.

Zusammenfassung Ziel der Studie Analyse der Beziehung zwischen depressiven Symptomen und funktionellen Beeinträchtigungen bei Hochaltrigen (85+) im Längsschnitt. Methodik Drei Wellen der multizentrischen prospektiven Kohortenstudie AgeQualiDe wurden genutzt (n = 1272 Beobachtungen). Die Geriatrische Depressionsskala wurde zur Erfassung depressiver Symptome verwendet. Die Instrumental Activities of Daily Living von Lawton und Brody wurde zur Messung funktioneller Beeinträchtigungen eingesetzt. Ergebnisse Anfängliche Steigerungen in depressiven Symptomen gehen mit späteren Steigerungen funktioneller Beeinträchtigungen einher. Hingegen hängen anfängliche Steigerungen funktioneller Beeinträchtigungen nicht mit späteren Steigerungen in depressiven Symptomen zusammen. Schlussfolgerung Unsere Ergebnisse deuten darauf hin, dass anfängliche Steigerungen depressiver Symptome mit einer Zunahme funktioneller Beeinträchtigungen bei Hochaltrigen zusammenhängen.

Der Beitrag befasst sich mit der Entwicklung der Arbeitszeiten und Arbeitszeitvorstellungen von Arztinnen und Arzten in Weiterbildung und untersucht, aus welchen Grunden Voll- bzw. Teilzeitmodelle praferiert werden. Datenbasis ist die KarMed-Studie, in deren Rahmen jahrliche postalische Befragungen von Absolventen des Medizinstudiums im Jahrgang 2008/2009 aus 7 medizinischen Fakultaten in Deutschland durchgefuhrt werden. Sie werden wahrend der gesamten Weiterbildungsdauer befragt. Die Rucklaufquote betrug 48 % im ersten Befragungsjahr, danach in allen Befragungen 85 % und mehr. Fur die Auswertung wurden deskriptive Statistiken und Regressionsanalysen angewandt. Es gibt deutliche Diskrepanzen zwischen den realen und den gewunschten Arbeitszeiten von Arztinnen und Arzten in Weiterbildung. Die Weiterbildung wird zumeist in Vollzeit absolviert, hinzu kommen Uberstunden, obwohl ein beachtlicher Anteil der Befragten eine Arbeit in Teilzeit praferiert. Arztinnen bevorzugen eher eine Teilzeittatigkeit als Arzte. Dasselbe gilt fur die Zeit nach der facharztlichen Anerkennung: Insbesondere Arztinnen mit Kind, Arztinnen, die in den alten Bundeslandern ausgebildet wurden und Arztinnen, die eine ambulante Tatigkeit anstreben, wunschen sich fur die Zukunft eine Teilzeitstelle. Auch bei den Mannern ist diese Tendenz uber die Jahre hinweg verstarkt zu beobachten. Trotz der grosen Zahl an Weiterzubildenden, die sich einen Teilzeitvertrag sowohl in der Weiterbildung als auch danach wunschen, ist die Realitat noch weit von derartigen Modellen entfernt. Fur die Zukunft wird deutlich, dass fur beide Geschlechter Masnahmen ergriffen werden sollten, die es erleichtern, das jeweils bevorzugte Arbeitszeitmodell fur den Einzelnen zu verwirklichen.

Zusammenfassung Hintergrund Untersucht wurden die Präferenzen von Ärztinnen und Ärzten in Weiterbildung in Bezug auf Tätigkeitssektor (ambulant/stationär) und die angestrebte Position im jeweiligen Sektor (Anstellung/Freiberuflichkeit bzw. fach-/ober-/chefärztliche Position) nach ihrer fachärztlichen Anerkennung. Im Fokus stehen dabei geschlechtsspezifische Unterschiede und Einfluss von Elternschaft. Methodik Jährliche standardisierte postalische Befragungen mit den Absolventinnen und Absolventen von medizinischen Fakultäten vom Praktischen Jahr bis nach vier Jahren Weiterbildung. Die Rücklaufquote betrug 48 % im 1. Jahr, in den Folgejahren stets 85 % und mehr. In allen Erhebungen waren ca. zwei Drittel der Befragten weiblich. Zur Datenauswertung wurden deskriptive Statistik und Regressionsanalysen angewandt. Ergebnisse Das Krankenhaus wird im Vergleich zur vertragsärztlichen Versorgung bevorzugt, auch wenn die Attraktivität des Krankenhauses über die vier Weiterbildungsjahre abnimmt. Die Entscheidung für oder gegen das Krankenhaus hängt mit der gewählten Disziplin zusammen. Ambulante Versorgung ist mit Möglichkeiten zur Teilzeittätigkeit assoziiert. In der vertragsärztlichen Versorgung wird von Männern eher eine Niederlassung, von Frauen zunehmend ein Angestelltenverhältnis präferiert. Personen mit Kind und Personen, die eine Vollzeittätigkeit in der ambulanten Versorgung anstreben, präferieren die Niederlassung in eigener Praxis. Im Krankenhaus streben vor allem Männer Positionen mit Leitungsfunktion an, Leitungsposition ist mit Vollzeittätigkeit assoziiert. Zukünftige Führungskräfte finden sich primär in Universitätskliniken. Folgerung Drei Tendenzen sind zu verzeichnen: Abneigung gegenüber Leitungspositionen, wachsendes Interesse an Teilzeitarbeit und wachsende Neigung zur Angestelltentätigkeit im ambulanten Sektor. Diese Tendenzen stellen eine Abkehr von traditionellen Leitbildern der medizinischen Profession dar. Die derzeitige Arbeitsmarktsituation erlaubt eine Realisierung dieser Präferenzen, damit einhergehenden Problemen der möglichen Unterversorgung muss deshalb von anderer Stelle entgegengewirkt werden. Ein Umdenken in der Geschlechterrollenverteilung ist kaum nachzuweisen.

Zusammenfassung Hintergrund Es wurde untersucht, in welcher Disziplin Ärztinnen und Ärzte nach 4 Jahren Weiterbildung ihre fachärztliche Anerkennung anstreben und die Ergebnisse mit denen vorhergehender Erhebungen verglichen. Im Fokus standen dabei geschlechtsspezifische Unterschiede und der Einfluss der Elternschaft. Methoden Es wurden jährlich standardisierte postalische Befragungen mit den Absolventinnen und Absolventen von 7 medizinischen Fakultäten vom Praktischen Jahr bis nach 4 Jahren Weiterbildung durchgeführt. Die Rücklaufquote betrug 48% im ersten Jahr und in den Folgejahren stets 85% und mehr. In allen Erhebungen waren etwa zwei Drittel der Befragten weiblich. Zur Datenauswertung wurden deskriptive Statistik und Regressionsanalysen angewandt. Ergebnisse Im Vergleich zum Ende des Medizinstudiums haben Anästhesiologie und Allgemeinmedizin an Beliebtheit gewonnen, während die chirurgischen Disziplinen über die Jahre ihre Attraktivität eingebüßt haben. Diese Entwicklungen fanden in beiden Geschlechtern statt. Innere Medizin mit Schwerpunkt, Kinderheilkunde und Frauenheilkunde verloren vor allem bei Frauen an Popularität. Disziplinpräferenzen hängen nachweislich mit dem bevorzugten Arbeitszeitmodell nach der Weiterbildung und mit dem Elternschaftsstatus zusammen. Schlussfolgerung Die Daten zeigen, dass nicht die „Feminisierung“ Grund für den Attraktivitätszuwachs der Anästhesiologie und Allgemeinmedizin ist, denn diese Entwicklungen waren in den 4 Jahren Weiterbildung in beiden Geschlechtern zu beobachten. Die abnehmende Beliebtheit der klinischen und insbesondere der schneidenden Disziplinen erhöhen das Risiko einer personellen Unterversorgung im Krankenhaus. Dieses Problem könnte durch die zunehmende Attraktivität von Teilzeitarbeit noch verstärkt werden.

Background Collaborative, nurse-led care is a well-established model of ambulatory care in many healthcare systems. Nurses play a key role in managing patients' conditions as well as in enhancing symptom- and self-management skills. Objective The SMADS trial evaluated the effectiveness of a primary care-based, nurse-led, complex intervention to promote self-management in patients with anxiety, depressive or somatic symptoms. Change in self-efficacy 12 months post baseline was used as the primary outcome. Design The SMADS trial set up a two-arm, cluster randomised controlled trial in the city of Hamburg, a large metropolitan area in the North West of Germany. Setting We randomly allocated participating primary care practices to either the intervention group (IG), implementing a nurse-led collaborative care model, or to the control group (CG), where patients with the above psychosomatic symptoms received routine treatment. Participants Patients from 18 to 65 years of age, regularly consulting a participating primary care practice, scoring≥5 on the anxiety, depressive or somatic symptom scales of the Patient Health Questionnaire (PHQ-D), German version. Methods A mixed model regression approach was used to analyse the outcome data. Analyses were based on the intention-to-treat population: All enrolled patients were analysed at their follow-up. Additionally, we reported results as effect sizes. The robustness of the results was investigated by performing an observed cases analysis. Results 325 participants (IG N=134, CG N=191) from ten practices in each study arm consented to take part and completed a baseline assessment. The mean group difference (ITT-LOCF, IG vs. CG) in self-efficacy at the post baseline follow-up (median 406days) was 1.65 points (95% CI 0.50–2.8) in favour of IG (p=0.004). This amounts to a small Cohen's d effect size of 0.33. An observed cases analysis (168 participants, IG=56, CG=105) resulted in a mean difference of 3.13 (95% CI 1.07–5.18, p=0.003) between the groups, amounting to a moderate effect size of d=0.51. Conclusion A complex, nurse-led intervention, implemented as a collaborative care model, increased perceived self-efficacy in patients with symptoms of anxiety, depression or somatisation compare to control patients. For the first time in the German healthcare system, the SMADS trial validated the belief that a nurse can successfully complement the work of a general practitioner – particularly in supporting self-management of patients with psychosomatic symptoms and their psychosocial needs.

There are very few studies examining the determinants of frequent attendance in primary care among the oldest old. The purpose of this study was to determine the characteristics of frequent attendance among individuals aged 85 years or older. Cross-sectional data stem from the multicenter prospective cohort “Study on needs, health service use, costs and health-related quality of life in a large sample of oldest old primary care patients (85 +)” (AgeQualiDe). This study covers very old primary care patients (n = 861, mean age of 89.0 years ± 2.9; 85–100 years). The number of self-reported GP visits in the preceding 3 months was used to quantify frequent attenders. We defined patients in the top decile as frequent attenders. Multiple logistic regressions showed that frequent attendance was associated with more chronic diseases (adjusted OR 1.12, 95% CI 1.01–1.23), worse functioning (OR 0.97, 95% CI 0.95–0.99), worries about one’s financial situation (OR 2.20, 95% CI 1.07–4.53) and it was inversely associated with depression (OR 0.26, 95% CI 0.08–0.80). In contrast to studies based on younger samples, different factors were associated with frequent users in our study, showing that it is important to study the determinants of frequent attendance among the oldest old. In Germany, among the group of the oldest old, frequent attendance was positively associated with worse physical health status (e.g., number of chronic diseases), but negatively with depression. This might indicate that the German health care system is responsive to the physical, but not psychological needs of the oldest old.

Evaluation of longitudinal data of German medical residents' career satisfaction and its dependency on perceived delays in obtaining the degree as a medical specialist, as well as postgraduate training quality, controlled for gender, parental status, and specialty choice.Data was collected within the KarMed study. The first data collection (T0) was conducted in 2008/2009 at the end of the practical year. Hierarchical linear models and path analysis were used to analyse longitudinal associations after three and five years (T3 to T5).A positive residents' career satisfaction had a small causal effect on the training quality. A delay in obtaining the degree as a medical specialist had a small negative effect on residents' career satisfaction. A high residents' career satisfaction was negatively associated with a delay in training. Gender predicted the career satisfaction of physicians with children. The career satisfaction of female physicians with children decreased significantly in the course of their postgraduate training compared to male physicians with children. The speciality choice had no significant impact on residents' career satisfaction.Residents who were satisfied with their job subjectively rated the quality of postgraduate training conditions more positively. The anticipated delays in obtaining the degree as a medical specialist and the residents' career satisfaction were reciprocally related. The improvement of career satisfaction in female physicians with children needs special attention in the future.

Objectives: On the basis of current treatment guidelines, we developed and validated a medication-based chronic disease score (medCDS) and tested its association with all-cause mortality of older outpatients.Study Design and Setting: Considering the most prevalent chronic diseases in the elderly German population, we compiled a list of evidence-based medicines used to treat these disorders. Based on this list, a score (medCDS) was developed to predict mortality using data of a large longitudinal cohort of older outpatients (training sample; MultiCare Cohort Study). By assessing receiver-operating characteristics (ROC) curves, the performance of medCDS was then confirmed in independent cohorts (ESTHER, KORA-Age) of community-dwelling older patients and compared with already existing medication-based scores and a score using selected anatomical-therapeutic-chemical (ATC) codes.Results: The final medCDS score had an ROC area under the curve (AUC) of 0.73 (95% CI 0.70-0.76). In the validation cohorts, its ROC AUCs were 0.79 (0.76-0.82, KORA-Age) and 0.74 (0.71-0.78, ESTHER), which were superior to already existing medication-based scores (RxRisk, CDS) and scores based on pharmacological ATC code subgroups (ATC3) or age and sex alone (Age&Sex).Conclusions: A new medCDS, which is based on actual treatment standards, predicts mortality of older outpatients significantly better than already existing scores. (C) 2018 Elsevier Inc. All rights reserved.

OBJECTIVE To analyze the association of anxiety symptoms with health care use and costs in people aged 85 and older. METHODS Baseline data from AgeQualiDe (N = 856), a multicenter prospective cohort study of primary care patients aged 85 and older, were analyzed. Anxiety symptoms (Geriatric Anxiety Inventory-Short Form) and health care use were assessed via questionnaires. Health care use was monetarily valued using German unit costs to obtain sectoral (inpatient, outpatient, nursing care, medical supplies, and medication) and total costs. Health care use and costs were analyzed in regression models as a function of anxiety symptoms, as well as relevant covariates (predisposing, enabling, and other need characteristics based on the Behavioral Model of Health Care Use). RESULTS On a descriptive level, people with increased anxiety symptoms (12% of the sample) incurred on average € 10 909 (SD: 16 023) in the last 6 months, 31% more than those without increased anxiety (€ 8303, SD: 11 175; P = 0.12). Adjusting for predisposing, enabling, and other need characteristics, anxiety symptoms were not significantly associated with health care use or costs. Specifically, need characteristics (morbidity, cognitive decline, and functional impairment) were associated with total or sectoral costs, depending on the cost category analyzed. CONCLUSION In a sample of people of the oldest-old age group, the severity of anxiety symptoms was not associated with health care use or costs, when adjusting for relevant covariates. A longitudinal analysis could assess whether a change in anxiety symptom severity is associated with health care use or costs in old age.

Aim To present data on the prevalence of driving habits and to identify the determinants of driving habits among the oldest old in Germany. Methods Cross-sectional data were used from the “Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)” (AgeQualiDe), including primary care patients aged 85 years and above (n = 549 at FU 9, mean age was 90.3 years; 86–101 years). Driving habits were measured (driving a car; frequency of driving a car and driving duration). Correlates were quantified using widely established scales (e.g., Geriatric Depression Scale, Instrumental Activities of Daily Living Scale). Multiple regression models were used to identify the determinants of driving habits. Results Sixteen percent (87 out of 549) drove a car. Among the car-drivers, about 80% drove at least several times a week and about two-thirds drove longer distances (>15 min). Multiple logistic regressions showed that among the oldest old being a male was more likely to be a current driver compared to being a female. Other significant factors were subjective memory impairment, severe visual impairment, functional and cognitive impairment. Correlates of frequency of driving a car and driving duration were further identified. Conclusion About one in six very old Germans is still a regular car driver. Several determinants of driving habits among the oldest old were identified. Future longitudinal studies are required to clarify the factors leading to changes in driving habits.

ObjectivesThe aims of our study were to examine the anticholinergic drug use and to assess the association between anticholinergic burden and cognitive function in the multimorbid elderly patients of the MultiCare cohort.SettingMultiCare was conducted as a longitudinal cohort study in primary care, located in eight different study centres in Germany.Participants3189 patients (59.3% female).Primary and secondary outcome measuresBaseline data were used for the following analyses. Drugs were classified according to the well-established anticholinergic drug scale (ADS) and the recently published German anticholinergic burden (German ACB). Cognitive function was measured using a letter digit substitution test (LDST) and a mixed-effect multivariate linear regression was performed to calculate the influence of anticholinergic burden on the cognitive function.ResultsPatients used 1764 anticholinergic drugs according to ADS and 2750 anticholinergics according to the German ACB score (prevalence 38.4% and 53.7%, respectively). The mean ADS score was 0.8 (±1.3), and the mean German ACB score was 1.2 (±1.6) per patient. The most common ADS anticholinergic was furosemide (5.8%) and the most common ACB anticholinergic was metformin (13.7%). The majority of the identified anticholinergics were drugs with low anticholinergic potential: 80.2% (ADS) and 73.4% (ACB), respectively. An increasing ADS and German ACB score was associated with reduced cognitive function according to the LDST (−0.26; p=0.008 and −0.24; p=0.003, respectively).ConclusionMultimorbid elderly patients are in a high risk for using anticholinergic drugs according to ADS and German ACB score. We especially need to gain greater awareness for the contribution of drugs with low anticholinergic potential from the cardiovascular system. As anticholinergic drug use is associated with reduced cognitive function in multimorbid elderly patients, the importance of rational prescribing and also deprescribing needs to be further evaluated.Trial registration numberISRCTN89818205.

In this paper we analysed healthcare costs in a sample of elderly patients suffering from multimorbidity. On the one hand, multimorbid individuals consume a disproportionally large share of healthcare resources. On the other hand, the patient specific number and combination of co-occurring single diseases result in inhomogeneous data leading to biased estimates when using traditional regression techniques. Therefore, we applied a mixture of regressions in order to control for unobserved heterogeneity focussing on the identification of multimorbidity patterns. We used a subsample of N = 1050 patients from a multicentre prospective cohort study of randomly selected multimorbid primary care patients aged 65 to 85 years in Germany (ISRCTN 89818205) who completed a detailed questionnaire on healthcare utilization during the 6-month period preceding the interview. Disease combinations of 1047 were included. We detected four different groups of patients with regard to total costs. These groups corresponded largely to findings from the epidemiological literature. The effect of the presence of an additional disease on costs differed between groups. Moreover, two diametrically opposed cost trends were detected with respect to the number of co-occurring diseases. While in one group costs increased with the number of co-occurring diseases, in a second group cost tended to decrease. Copyright © 2016 John Wiley & Sons, Ltd.

Purpose: Psychosomatic symptoms and mental health problems are highly prevalent in multimorbid elderly people challenging general practitioners to differentiate between normal stress and psychopathological conditions. The 4DSQ is a Dutch questionnaire developed to detect anxiety, depression, somatization, and distress in primary care. This study aims to analyze measurement equivalence between a German version and the original Dutch instrument. Methods: A Dutch and a German sample of multimorbid elderly people, matched by gender and age, were analyzed. Equivalence of scale structures was assessed by confirmatory factor analysis (CFA). To evaluate measurement equivalence across languages, differential item functioning (DIF) was analyzed using Mantel–Haenszel method and hybrid ordinal logistic regression analysis. Differential test functioning (DTF) was assessed using Rasch analysis. Results: A total of 185 German and 185 Dutch participants completed the questionnaire. The CFA confirmed one-factor models for all scales of both 4DSQ versions. Nine items in three scales were flagged with DIF. The anxiety scale showed to be free of DIF. DTF analysis revealed negligible scale impact of DIF. Conclusions: The German 4DSQ demonstrated measurement equivalence to the original Dutch instrument. Hence, it can be considered a valid questionnaire for the screening for mental health problems in primary care.

The goal of the present retrospective study was to focus on the potential influence of polypharmacy on the initiation of antidementia therapy in patients diagnosed with dementia in general practices in Germany. The current study sample included patients diagnosed with dementia in 1,217 general practices in Germany between 2014 and 2016 (index date). The primary outcome measure was the rate of prescription of anti-dementia drugs within one year following the index date. The explanatory variable was the number of different drugs prescribed at baseline per patient. Independent variables included age, sex, and type of dementia. Logistic regression analyses were conducted to study the impact of the number of different drugs prescribed at baseline per participant on the odds of receiving anti-dementia therapy (in all patients and in patients diagnosed with Alzheimer's disease). The study included 21,888 patients with all-cause dementia. Mean age was 80.2 years (SD = 7.3 years) and 61.4% of the study population were women. Individuals receiving six drugs or more at baseline were significantly less likely to be prescribed anti-dementia treatment when compared to those without any drug at baseline (6- 9 drugs: odds ratio [OR] = 0.75;≥10 drugs: OR = 0.58). In the subgroup of patients with Alzheimer's disease, the odds of being prescribed anti-dementia therapy were lower in individuals with four drugs or more, compared to patients who had not been prescribed any drugs at baseline (4- 5 drugs: OR = 0.60; 6- 9 drugs: OR = 0.49;≥10 drugs: OR = 0.36). There is a negative association between polypharmacy and antidementia therapy initiation in general practices in Germany.

Background: Evidence whether single &ldquo, cognitive health&rdquo, foods could prevent cognitive decline is limited. We investigated whether dietary intake of red wine, white wine, coffee, green tea, olive oil, fresh fish, fruits and vegetables, red meat and sausages, assessed by a single-food-questionnaire, would be associated with either incident Alzheimer&rsquo, s dementia (AD) or verbal memory decline. Methods: Participants aged 75+ of the German Study on Aging, Cognition and Dementia in Primary Care Patients (AgeCoDe) cohort were regularly followed over 10 years (n = 2622, n = 418 incident AD cases). Multivariable-adjusted joint modeling of repeated-measures and survival analysis was used, taking gender and Apolipoprotein E4 (APOE &epsilon, 4) genotype into account as possible effect modifiers. Results: Only higher red wine intake was associated with a lower incidence of AD (HR = 0.92, P = 0.045). Interestingly, this was true only for men (HR = 0.82, P &lt, 0.001), while in women higher red wine intake was associated with a higher incidence of AD (HR = 1.15, P = 0.044), and higher white wine intake with a more pronounced memory decline over time (HR = &minus, 0.13, P = 0.052). Conclusion: We found no evidence for these single foods to be protective against cognitive decline, with the exception of red wine, which reduced the risk for AD only in men. Women could be more susceptible to detrimental effects of alcohol.

Background Potentially inappropriate medication (PIM) is associated with an increased risk for detrimental health outcomes in elderly patients. Some antidepressant drugs are considered as PIM, but previous research on the association between antidepressants and subsequent dementia has been inconclusive. Therefore, we investigated whether the intake of antidepressants, particularly of those considered as PIM according to the Priscus list, would predict incident dementia. Methods We used data of a prospective cohort study of non-demented primary care patients (n = 3239, mean age = 79.62) to compute Cox proportional hazards models. The risk for subsequent dementia was estimated over eight follow-ups up to 12 years depending on antidepressant intake and covariates. Results The intake of antidepressants was associated with an increased risk for subsequent dementia (HR = 1.53, 95% CI: 1.16–2.02, p = .003; age-, sex-, education-adjusted). PIM antidepressants (HR = 1.49, 95% CI: 1.06–2.10, p = .021), but not other antidepressants (HR = 1.04, 95% CI: 0.66–1.66, p = .863), were associated with an increased risk for subsequent dementia (in age-, sex-, education-, and depressive symptoms adjusted models). Significant associations disappeared after global cognition at baseline was controlled for. Limitations Methodological limitations such as selection biases and self-reported drug assessments might have influenced the results. Conclusions Only antidepressants considered as PIM were associated with an increased subsequent dementia risk. Anticholinergic effects might explain this relationship. The association disappeared after the statistical control for global cognition at baseline. Nonetheless, physicians should avoid the prescription of PIM antidepressants in elderly patients whenever possible.

Background The homeless are often in poor health, and their risk of premature death is three to four times that of the general population. This article is intended to provide an overview of the medical care of the homeless in Germany. Methods We selectively reviewed pertinent scientific and non-scientific publications from the years 2000-2017 that were retrieved from PubMed, from the reports of the German Homeless Aid Society (Bundesarbeitsgemeinschaft Wohnungslosenhilfe), from the websites of homeless aid organizations, and from Google Scholar. Results At least 75% of the homeless currently suffer from a mental illness requiring treatment. Common somatic problems include respiratory (6-14%) and cardiovascular disorders (7-20%), injuries and intoxications (5-15%), and infectious and parasitic diseases (10-16%). To circumvent the multiple barriers impeding homeless people's access to standard medical care (lack of health insurance, a feeling of being unwelcome, lack of disease awareness, impaired capacity for compliance), medical help is offered to them outside the system in a number of ways, embedded in an overall scheme of social and practical assistance with daily living. These medical resources differ from region to region. They are often underfinanced and tend to focus on acute general medical care, with limited access to specialists. Conclusion More heath care resources need to be made available to the homeless beyond standard medical care. Concrete suggestions are discussed in the text.