Dementia In Germany Research Articles

Demenz in Deutschland – Ergebnisse eines interdisziplinären Expertenworkshops

In the aging population of Germany the consequences of Dementia for the society and the health care sector are complex and solutions require a multidisciplinary approach. The aim of the two-day interdisciplinary expert conference was to consider dementia from different perspectives, to identify dementia-related problems and to discuss integrative solutions under consideration of complementary therapies. In different working groups the experts developed solutions and recommendations with regards to political need, health care and future research priorities. The present recommendations profited very much from the interdisciplinary participants of the conference and brought together the expertise of different fields resulting in a comprehensive picture about dementia in Germany.

Diagnostik und Verlauf von kognitiven Fähigkeiten bei älteren Menschen

The assessment of the appropriate level of development in children belongs to the standard duties of physicians in the public health system. Due to a steady increase of dementia in Germany the assessment of cognitive abilities of the elderly is becoming more and more the focus of future activities. Such an assessment of cognitive functioning reveals whether the respective person is aging normally or whether the impaired cognitive functioning is probably based on a pathological process. The aim of the present study is to present cognitive changes in the aged and 2 psychometric tests for the assessment of cognitive functioning: the Wechsler Adult Intelligence Scale (WAIS-IV) and the Short Cognitive Performance Test (SKT), a test for the assessment of memory impairments and impairment of attention. In addition, similarities and dissimilarities are presented. As part of a multi-centre study in German-speaking countries the data of 504 cognitively healthy persons between the age of 60 and 90 were tested with the WAIS-IV and the SKT. The results revealed a significant cognitive decline in the fluid and crystal intelligence depending on age. Only 2 subtests of the WAIS-IV (General Information and Block Design) showed no significant variation due to age. The SKT scores of memory and attention correlated significantly with almost all subtests of the WAIS-IV. The highest correlations were between the SKT attention score and the WAIS-IV subtests for processing speed, perceptual reasoning and working memory. The decline in cognitive abilities is mainly due to reduced capacities in speed of information processing and working memory.

Age of onset in chronic diseases: new method and application to dementia in Germany

BackgroundAge of onset is an important outcome to characterize a population with a chronic disease. With respect to social, cognitive, and physical aspects for patients and families, dementia is especially burdensome. In Germany, like in many other countries, it is highly prevalent in the older population and imposes enormous efforts for caregivers and society.MethodsWe develop an incidence-prevalence-mortality model to derive the mean and variance of the age of onset in chronic diseases. Age- and sex-specific incidence and prevalence of dementia is taken from published values based on health insurance data from 2002. Data about the age distribution in Germany in 2002 comes from the Federal Statistical Office.ResultsMean age of onset of a chronic disease depends on a) the age-specific incidence of the disease, b) the prevalence of the disease, and c) the age distribution of the population. The resulting age of onset of dementia in Germany in 2002 is 78.8 ± 8.1 years (mean ± standard deviation) for men and 81.9 ± 7.6 years for women.ConclusionsAlthough incidence and prevalence of dementia in men are not greater than in women, men contract dementia approximately three years earlier than women. The reason lies in the different age distributions of the male and the female population in Germany.

Dying With Dementia

No detailed information has been available until now about the care setting, circumstances and place of death, symptom burden, and quality of care of persons with end-stage dementia in Germany. This cross-sectional study is based on a random sample of 5000 persons who died in the period from 25 May to 24 August 2008 in the German federal state of Rhineland-Palatinate. Their surviving relatives were contacted and asked to participate in a questionnaire survey. Data were obtained in this way for 310 persons with dementia and 931 persons without dementia. 42.4% of the persons with dementia died at home. Most patients and their relatives preferred death at home to death anywhere else (94.8% of patients, 77.5% of relatives). Persons living with at least one relative were more likely to die at home (adjusted odds ratio [aOR] 4.69, 95% confidence interval [CI] 2.71-8.11). According to information supplied by the relatives, the overwhelming majority of patients suffered, two days before death, from moderate to severe weakness (94.9%), fatigue (94.4%), disorientation/confusion (86.9%), and appetite loss (86.4%). Other common symptoms were anxiety (61.0%), tension (59.9%), dyspnea (56.7%), and pain (52.5%). The relatives were critical of the quality of care on standard hospital wards, citing the limited temporal availability of staff and limited emotional support. These data indicate the high symptom burden of persons with dementia in Germany at the end of their lives. They underscore the need for proper palliative care in all of the settings where persons with dementia die. Specialized in- and outpatient palliative care should not be offered only to patients with cancer, but should rather be made available to all who need it.

O3‐07‐04: Differences between clinical guidelines and daily care for dementia in Germany: A comparison based on health services research data

O3‐07‐04: Differences between clinical guidelines and daily care for dementia in Germany: A comparison based on health services research data

Low-threshold support for families with dementia in Germany

BackgroundLow-threshold support services are a part of the German health care system and help relieving family caregivers. There is limited information available on how to construct and implement low-threshold support services for people with dementia and their families in Germany. Some studies describe separately different perspectives of experiences and expectations, but there is no study combining all the different perspectives of those involved and taking the arrangements and organisation as well as their opinions on supporting and inhibiting factors into consideration.FindingsThis protocol describes the design of the study on low-threshold support services for families with a person with dementia in two German regions. The aim is to develop recommendations on how to build up these services and how to implement them in a region. A quantitative as well as a qualitative approach will be used. The quantitative part will be a survey on characteristics of service users and providers, as well as health care structures of the two project regions and an evaluation of important aspects derived from a literature search. Group discussions and semi-structured interviews will be carried out to get a deeper insight into the facilitators and barriers for both using and providing these services. All people involved will be included, such as the people with dementia, their relatives, volunteers, coordinators and institution representatives.DiscussionResults of this study will provide important aspects for policymakers who are interested in an effective and low-threshold support for people with dementia. Furthermore the emerging recommendations can help staff and institutions to improve quality of care and can contribute to developing health and social care structures in Germany.

Antidementia drug prescription sources and patterns after the diagnosis of dementia in Germany

We examined the patterns of prescription for antidementia drugs by German physicians with special reference to source of prescription, appropriateness of drugs and dosages and continuity of prescription patterns. The study is based on claims data of all 1848 incident cases in persons aged 65 years and older from a nationwide operating statutory health insurance company in the years 2004-2006. Inclusion criteria were one International Statistical Classification of Diseases and Related Health Problems 10th Revision code for dementia in at least three of four consecutive quarters and four quarters without such a code beforehand. Defined daily doses were used to quantify the prescription size. Data analysis used univariate and multivariate techniques. The majority of incident dementia cases in general and Alzheimer's disease cases in particular did not receive medication in conformity with the guidelines during the year after incidence. Inappropriate prescription was related to not visiting a specialist, living in urban areas, age and comorbidity. Further research is needed both on reasons for nonprescription among professionals and for discontinuation by the patients. In addition, the problems of practicability and implementation of guidelines deserve more attention.

P4‐333: Improving health care for people with dementia in Germany: The DelpHi study

P4‐333: Improving health care for people with dementia in Germany: The DelpHi study

Health care of people with dementia in Germany in 2030 - a multidisciplinary scenario approach (Sce-Dem)

Health care of people with dementia in Germany in 2030 - a multidisciplinary scenario approach (Sce-Dem)

Specialist involvement and referral patterns in ambulatory medical care for patients with dementia in Germany: results of a claims data based case-control study

BackgroundTo analyze the referral processes from general practitioners to specialists and among specialists for dementia patients in the time periods before, during and after the diagnosis in Germany.MethodsIn this case-control study claims data from 1,848 insurants with incident dementia aged 65 years and more and 7,392 matched controls were compared over a two-year period covering the pre-incidence, incidence and post-incidence time periods.ResultsWe found an increase in referrals of 30% in the incidence quarter, mainly from general practice to neuropsychiatry and from there to radiology. Referrals to clinical chemistry and other disciplines for dementia-specific reasons were negligible in amount. 34% of incident cases had at least one contact with a neuropsychiatrist during the year of incidence, and the majority of them visited this specialist repeatedly during that year. Only a minority (13.5%) of patients was referred to radiology for imaging. Referrals to other specialists declined whereas self-referrals did not increase.ConclusionsThe referral rates to relevant specialists (neuropsychiatry, radiology and clinical chemistry) are far less frequent than proposed in German guidelines. More research is needed to explain the gape between guidelines and daily care and to find ways for a better implementation of guidelines in ambulatory care. Guidelines should not only deal with diagnostic procedures and therapeutic options but also consider questions of applicability in daily clinical practice and propose effective organizational models of care provision.

Stellungnahme zur S3-Leitlinie Demenzen der DGPPN und der DGN aus psychiatrischer Sicht

The S 3 guidelines Dementia from the DGPPN and DGN represent recommendations that fulfil the highest methodological requirements and are based on a consensus process involving all professional societies, associations and organisations that participate in the management of patients with dementia. From the psychiatric point of view, in particular, the broad representation of the diagnostic processes, the inclusion of modern liquor diagnostics, the comprehensive presentation of psychosocial interventions and the detailed description of psychiatric and behavioural symptoms are unique features. The guidelines provide the foundation for substantial improvement in the management of patients with dementia in Germany.

Utilization Patterns of Ambulatory Medical Care before and after the Diagnosis of Dementia in Germany – Results of a Case-Control Study

Aims: To analyze how the diagnosis of dementia changes the utilization of the ambulatory medical care services in the German statutory health insurance. Methods: In this case-control study, claims data of 1,848 insurants aged ≧65 years with incident dementia and 7,392 matched controls were compared regarding their utilization of ambulatory medical care services. Results: We found an increase in the utilization of ambulatory medical care services by demented patients of 50% in the year before and of 40% in the year after the incidence, predominantly in primary care and neurology/psychiatry settings. A negative interaction effect of age and gender (p ≤ 0.000) was found regarding the number of visited physicians. Conclusion: Service utilization by demented patients increases already within the year before the first diagnosis and stays on a relatively high level within the year after. Especially (female) patients aged 80 years and older at dementia onset ought to be observed to prevent a possible undersupply.

Concepts of care for people with dementia.

IntroductionToday there are approximately one million people with dementia in Germany. If current demographic trends continue, this number is likely to rise substantially in the coming years. In the older population, dementia is the most frequent reason for long-term care. Because most forms of dementia cannot be cured, the aim of treatment is to delay disease progression and to maintain functioning and quality of life.Research questionsWhat is the evidence on different approaches to the long-term usual care of patients with dementia in terms of common endpoints such as quality of life, and social behaviour? How is the cost-effectiveness of these concepts to be evaluated? Which ethical, social, or legal issues are discussed in this context?MethodsBased on a systematic literature review, we include randomized, controlled studies that had at least 30 participants and investigated one or more of the following approaches of dementia care: validation therapy/emotion-oriented usual care, ergotherapy, sensory stimulation, relaxation techniques, reality orientation therapy, and reminiscence therapy. Studies had to be published after 1996 (after 1990 for the economic part) in English or German.ResultsA total of 20 studies meet the inclusion criteria. Of these, three focus on validation therapy/emotion-oriented usual care, five on ergotherapy, seven on different kinds of sensory stimulation, two on reality orientation, two on reminiscence therapy, and one on a type of relaxation technique. There are no significant differences between the intervention and control groups in two of the three studies on validation therapy or emotion-oriented usual care, in two of the five studies on ergotherapy, in three of the seven studies on sensory stimulation, in both of the two studies on reminiscence therapy, and in the one study on relaxation. In the remaining ten studies, seven report some positive results in favour of the respective interventions, and three studies (ergotherapy, aroma therapy, and music/massage) report positive effects with respect to all of the endpoints measured. Six publications present economic results for usual-care-concepts. One study reports additional costs of 16 GBP (24.03 Euro (2006)) per patient per week for occupational therapie. Two publications declare incremental cost of 24.30 USD (25.62 Euro (2006)) per mini-mental-state-examination-(MMSE)-point gained per month respectively 1,380,000 ITL (506.21 Euro (2006)) per MMSE-point gained. Two publications focus on mixed interventions. One study reports the additional costs of an activity program (1.13 USD (1.39 Euro (2006)) per day per patient) and the other additional time for the usual care for mobile demented patients (average of 45 minutes per day per patient).With respect to ethical and social aspects the discussion focusses on the problem of autonomy: dementia does not necessarily mean inability to decide over the participtation in studies. Legal questions address the financial situation of patients, the organisation of their care and the legal representation of dementia patients.DiscussionOnly a few studies on the nursing interventions considered in this report are methodologically robust. Most of the studies have a small number of participants and show substantial differences in terms of their inclusion criteria, implementation, and endpoints.This heterogeneity is reflected in the results: in half of the studies, the interventions have no positive effects compared to the control group. The other half of the studies reports some positive effects with regard to specific endpoints. All of the economic studies are, from a methodologial and a thematic standpoint, not suitable to answer the questions raised. Ethical, social and legal aspects are discussed but not systematically analysed. ConclusionThe studies conducted to date do not provide sufficient evidence of neither efficacy nor cost-effectiveness for any of the nursing interventions considered in the present HTA. However, lack of evidence does not mean lack of efficacy. Instead, more methodologically sound studies are needed. Particullary desireable are studies reflecting the framework of dementia care in Germany. This holds also for the healtheconomic evaluations of the chosen interventions.

NMDA-antagonism (memantine): an alternative pharmacological therapeutic principle in Alzheimer's and vascular dementia.

Memantine, a non-competitive NMDA antagonist, has been clinically used in the treatment of dementia in Germany for over ten years. The rationale for this indication is strongly related to the physiological and to the pathological role of glutamate in neurotransmission. Physiologically, NMDA receptors mediate synaptic plasticity by acting as a coincidence detector. Only those synapses that show temporally and spatially discrete activation of NMDA receptors undergo plastic changes secondary to Ca++ influx after rapid unblocking of Mg++, thus crucially contributing to memory and learning processes. The voltage-dependency of Mg++ is so pronounced that under pathological conditions it leaves the NMDA channel upon moderate depolarisation, thus interrupting memory and learning. Its pharmacological properties allow memantine to rapidly leave the NMDA channel upon transient physiological activation by synaptic glutamate (restoring significant signal transmission), but to block the sustained activation of low glutamate concentration under pathological conditions, i.e. to protect against excitotoxicity as a pathomechanism of neurodegenerative disorders. Memantine acts as a neuroprotective agent in various animal models based on both neurodegenerative and vascular processes as it ameliorates cognitive and memory deficits. Memantine has shown to be effective and safe in the treatment of dementia, particularly Alzheimer's disease, in controlled clinical trials. Provided that the dose is slowly increased it is generally well tolerated and safe up to 20 and 30 mg per day, with intake preferably in the morning. The compound is completely absorbed after oral intake with Cmax values after 6 hours, undergoes little metabolism and has a terminal elimination half life between 60 and 100 hours. Due to its low potential of interaction, memantine can be combined with acetylcholinesterase inhibitors, the mainstay of current symptomatic treatment of Alzheimer's disease and it is suited in elderly patients receiving multiple drug therapy.

Evaluation of memantine for neuroprotection in dementia

Memantine, a non-competitive NMDA antagonist, has been approved for use in the treatment of dementia in Germany for over ten years. The rationale for use is excitotoxicity as a pathomechanism of neurodegenerative disorders. Memantine acts as a neuroprotective agent against this pathomechanism, which is also implicated in vascular dementia. HIV-1 proteins Tat and gp120 have been implicated in the pathogenesis of dementia associated with HIV infection and the neurotoxicity caused by HIV-1 proteins can be blocked completely by memantine. Memantine has been investigated extensively in animal studies and following this, its efficacy and safety has been established and confirmed by clinical experience in humans. It exhibits none of the undesirable effects associated with competitive NMDA antagonists such as dizocilpine. The efficacy of memantine in a variety of dementias has been shown in clinical trials. Memantine is considered to be a promising neuroprotective drug for the treatment of dementias, particularly Alzheimer’s disease for which there is no neuroprotective therapy available currently. It can be combined with acetylcholinesterase inhibitors which are the mainstay of current symptomatic treatment of Alzheimer’s disease. Memantine has a therapeutic potential in numerous CNS disorders besides dementias which include stroke, CNS trauma, Parkinson’s disease (PD), amyotrophic lateral sclerosis (ALS), epilepsy, drug dependence and chronic pain. If memantine is approved by the FDA for some of these indications by the year 2005, it can become a blockbuster drug by crossing the US$1 billion mark in annual sales.

Dementia syndrome and Alzheimer disease: an assessment of morbidity and annual incidence in Germany

Due to the increasing life expectancy and the growing number of elderly people, dementia is emerging as a major health problem. There is, however, a lack of consistent data on the number of prevalent and incident cases of dementia in Germany. The aim of the present study was to estimate the prevalence and the incidence of dementing disorders in general as well as Alzheimer's disease in particular on the basis of disease rates based on large-scale epidemiological field studies and meta-analyses, which were standardized according to the age structure of the German population. The results show that probably more than 900,000 persons in Germany suffer from a dementing illness, 650,000 among them from Alzheimer's disease. About 200,000 new cases of dementia develop during one year, among them 120,000 new cases of Alzheimer's disease. Due to the higher life expectancy of women as compared to men 70% of the patients are of female gender. As a consequence of the steep increase of disease rates with age, two-thirds of the prevalent cases and 60% of the incident cases are found among people in the age bracket of 80 and over, whereas only 3% are found among persons younger than 65 years of age. Additionally, an estimate of the distribution of cases by the 16 Federal states of Germany is given.