Benzinger, Petra
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Der gesetzlich verbesserte Zugang zur geriatrischen Rehabilitation – Voraussetzungen und Schwächen
(2024)
Geriatric rehabilitation is a cornerstone of the German healthcare system to maintain the functional capacity of older patients and prevent the need for long-term care. Until recently, access to geriatric rehabilitation was largely limited to post-acute care. With the introduction of new legislation, patients aged 70 and over can be referred to geriatric rehabilitation by practitioners. However, in order to prescribe geriatric rehabilitation, physicians must document relevant diagnoses supported by the results of a series of functional or cognitive assessments. Alongside this information, the SINGER profile has been introduced. It is mandatory, although there is currently no manual to guide assessment with this tool. Diagnoses and test results must be consistent in documenting the need for geriatric rehabilitation. However, individual assessment of resources and motivation are prerequisites that need to be assessed by prescribing practitioners prior to prescription, considering the structure of the available formats. First analyses document improvement in access to geriatric rehabilitation but point to limited availability.
Bewegen und Stärken: Gesundheitsförderung in der Alltagsbegleitung (BeStärken+) – Projektvorstellung
(2024)
Hintergrund:
In Deutschland leben 5 Mio. Menschen mit Pflegebedarf, davon rund 80 % im ambulanten Bereich (Statistisches Bundesamt, 2023). Dabei weisen Pflegebedürftige das geriatrische Syndrom Frailty auf. Die Wirksamkeit von bewegungsbezogenen Interventionen bei Menschen mit Frailty konnte bereits auf verschiedene Variablen nachgewiesen werden (u. a. Casas‐Herrero et al., 2022). Mitunter kann es zu einer Zunahme der Leistungsfähigkeit kommen und das Sturzrisiko und somit die Gefahr schwerwiegender Verletzungen reduzieren. Der Umsetzung solcher Interventionen stehen oftmals der Fachkräftemangel und begrenzte Angebote im ländlichen Raum entgegen. Das Projekt „Bewegen und Stärken: Gesundheitsförderung in der Alltagsbegleitung“ hat zum Ziel, durch Einbindung von Alltagsbegleitern als Nicht-Fachkräfte Zugang zu Pflegebedürftigen zu erhalten, um gesundheitsförderliche Aktivitäten im häuslichen Setting umzusetzen.
Methode:
Die auf 3 Jahre ausgelegte Machbarkeitsstudie gliedert sich in eine Vor- und Hauptstudie. Ziel ist die Rekrutierung von 80 „Pflegetriaden“ bestehend aus a) Alltagsbegleitern, b) Pflegebedürftigen und c) Angehörigen. In der Vorstudie werden qualitative Interviews geführt, um die BeStärken+-Interventions- und Fortbildungsinhalte zu optimieren und im Rahmen der Hauptstudie in die Regelversorgung einzubetten. Geplante Befragungsinhalte der Hauptstudie sind auch Frailty-Merkmale.
Ergebnisse:
In der Vorbereitungsphase wurden evidenzbasierte, gesundheitsförderliche Aktivitäten herausgearbeitet und mit Experten u. a. aus den Bereichen der Gerontologie, Sporttherapie, Psychotherapie und mit Trägern und Alltagsbegleitern diskutiert. Im nächsten Schritt sollen Pflegetriaden für die Vorstudie rekrutiert und die ersten Alltagsbegleiter eine BeStärken+-Fortbildung erhalten.
Diskussion:
Aktuell offene Fragen stellen sich in Bezug auf Zugangsmöglichkeiten zu bestehenden Triaden, die Motivation zur Teilnahme und Umsetzbarkeit gesundheitsförderlicher Aktivitäten durch Nicht-Fachkräfte sowie letztlich wie eine nachhaltige Implementierung bei Trägern aussehen könnte.
Literatur:
Statistisches Bundesamt. (22. Februar 2023). Mehr Pflegebedürftige. Abruf unter https://www.destatis.de/DE/Themen/Querschnitt/Demografischer-Wandel/Hintergruende-Auswirkungen/demografie-pflege.html
Casas‐Herrero, Á., Sáez de Asteasu, M. L., Antón‐Rodrigo, I., Sánchez‐Sánchez, J. L., Montero‐Odasso, M., Marín‐Epelde, I. et al. (2022). Effects of Vivifrail multicomponent intervention on functional capacity: a multicentre, randomized controlled trial. Journal of Cachexia, Sarcopenia and Muscle, 13(2), 884-893.
Ein Sturz ist ein Ereignis, bei dem eine Person unbeabsichtigt zu Fall kommt. Stürze sind dabei nicht als Erkrankung, sondern als Ereignisse bzw. Unfälle aufzufassen. Das Sturzgeschehen ist ein geriatrisches „Kernsyndrom“, d. h. es ist Folge verschiedener Krankheits- und Alterungsprozesse und gehört zu den dominierenden Problemen hochaltriger Menschen. Ärztliches Handeln sollte neben der Behandlung sturzbedingter Verletzungen darauf gerichtet sein, Stürze und sturzbedingte Verletzungen zu verhindern. Hierfür ist ein Verständnis für das Zusammenspiel von intrinsischen, extrinsischen und situativen (Risiko-)Faktoren notwendig.
Background
Geriatric rehabilitation aims to maintain the functional reserves of older adults in order to optimize social participation and prevent disability. After discharge from inpatient geriatric rehabilitation, patients are at high risk for decreased physical capacity, increased vulnerability, and limitations in mobility. As a result, ageing in place becomes uncertain for a plethora of patients after discharge from geriatric rehabilitation and effective strategies to prevent physical decline are required. Collaboration between different health-care providers is essential to improve continuity of care after discharge from inpatient geriatric rehabilitation. The aim of this study is to evaluate the effectiveness of a multi-professional home-based intervention program (GeRas) to improve functional capacity and social participation in older persons after discharge from inpatient geriatric rehabilitation.
Methods
The study is a multicenter, three-arm, randomized controlled trial with a three-month intervention period. Two hundred and seventy community-dwelling older people receiving inpatient geriatric rehabilitation will be randomized with a 1:1:1 ratio to one of the parallel intervention groups (conventional IG or tablet IG) or the control group (CG). The participants of both IGs will receive a home-based physical exercise program supervised by physical therapists, a nutritional recommendation by a physician, and social counseling by social workers of the health insurance company. The collaboration between the health-care providers and management of participants will be realized within a cloud environment based on a telemedicine platform and supported by multi-professional case conferences. The CG will receive usual care, two short handouts on general health-related topics, and facultative lifestyle counseling with general recommendations for a healthy diet and active ageing. The primary outcomes will be the physical capacity measured by the Short Physical Performance Battery and social participation assessed by the modified Reintegration to Normal Living Index, three months after discharge.
Discussion
The GeRas program is designed to improve the collaboration between health-care providers in the transition from inpatient geriatric rehabilitation to outpatient settings. Compared to usual care, it is expected to improve physical capacity and participation in geriatric patients after discharge from inpatient geriatric rehabilitation.
During the early stages of the COVID-19 pandemic, stringent measures were implemented in most countries to limit social contact between residents of long-term care facilities (LTCF) and visitors. The objective of this scoping review was to identify and map evidence of direct and indirect consequences of contact restrictions, guided by three conceptual perspectives: (1) stress and learned helplessness (i.e., failure to use coping behaviors even when they are available and actionalble); (2) social contact loss; and (3) ‘total institution’ (i.e., a facility operates following a fixed plan due to spelled-out rules and norms, controlled by institutional representatives). We used the framework for conducting a scoping review by Arksey and O'Malley; included were peer-reviewed manuscripts reporting on the outcomes of contact restrictions from the beginning of the pandemic until the end of 2020. After removing duplicates, 6,656 records were screened and 62 manuscripts included. Results pertaining to the stress and learned helplessness perspective primarily focused on depressive symptoms, showing substantial increases compared to the pre-pandemic period. Studies examining cognitive and functional decline, as well as non-COVID-19 related mortality, were limited in number and presented mixed findings. The majority of study outcomes related to the social contact loss perspective focused on loneliness, but the study designs did not adequately allow for comparisons with the pre-pandemic status. The evidence concerning outcomes related to the 'total Institution' perspective was inconclusive. Although detrimental effects of social isolation in the long-term care context found support particularly in the negative affect domain, other outcome areas did not allow for definitive conclusions due to considerable variations in findings and, in some cases, insufficient statistical power.
Validation of a telephone-based administration of the simplified nutritional appetite questionnaire
(2023)
Background:
Anorexia of aging is characterized by an age-associated reduction of appetite, whose aetiology in most cases is multifactorial and which often triggers malnutrition. The Simplified Nutritional Appetite Questionnaire (SNAQ) is an established screening tool. This study aimed to investigate reliability, validity, and feasibility of its telephone administration (T-SNAQ) in German community-dwelling older adults.
Methods:
This cross-sectional single-centre study recruited participants from April 2021 to September 2021. First, the SNAQ was translated into German according to an established methodology. After translation, reliability, construct validity, and feasibility of the T-SNAQ were analysed. A convenience sample of community-dwelling older adults aged ≥70 years was recruited. The following measurements were applied to all participants: T-SNAQ, Mini Nutritional Assessment – Short Form (MNA-SF), six-item Katz index of independence in activities of daily living (ADL), eight-item Lawton instrumental activities of daily living (IADL), telephone Montreal Cognitive Assessment (T-MoCA); FRAIL scale, Geriatric Depression Scale (GDS-15) and Charlson co-morbidity index as well as daily caloric and protein intake.
Results:
One hundred twenty participants (59.2% female) with a mean age of 78.0 ± 5.8 years were included in the present study. The percentage of participants identified with poor appetite based on T-SNAQ was 20.8% (n = 25). TSNAQ showed a good internal reliability with a Cronbach’s alpha coefficient of 0.64 and a good test–retest reliability [intraclass coefficient of 0.95 (P < 0.05)]. Regarding construct validity, T-SNAQ was significantly positively correlated
with MNA-SF (r = 0.213), T-MoCA (r = 0.225), daily energy (r = 0.222) and protein intake (r = 0.252) (P < 0.05). It also demonstrated a significant negative association with GDS-15 (r = 0.361), FRAIL scale (r = 0.203) and Charlson co-morbidity index (r = 0.272). Regarding applicability, the mean time for T-SNAQ was 95 s and completion rate was 100%.
Conclusions:
The T-SNAQ is a feasible screening instrument for anorexia of aging in community-dwelling older adults via telephone interviews.
Many patients in geriatric rehabilitation (GR) are physically frail at the time of admission and suffer from malnutrition and sarcopenia, which may worsen rehabilitation outcomes. This study aims to obtain insight into the current nutritional care practices in GR facilities across Europe.
Methods: In this cross-sectional study, a questionnaire focused on nutritional care practices in GR was distributed across experts in EUGMS member countries. Data were analyzed by using descriptive statistics. Results: In total, 109 respondents working in 25 European countries participated, and the results showed that not all GR patients were screened and treated for malnutrition, and not all participants used (inter)national guidelines when performing nutritional care. The results also showed variations across European geographical areas related to screening and treatment of malnutrition, sarcopenia, and frailty. Even though the participants underlined the importance of dedicating time to nutritional care, they experienced barriers in its implementation, which were mostly due to a lack of resources.
Conclusion: As malnutrition, sarcopenia, and frailty are often
present in patients admitted to GR, in addition to being interrelated, it is recommended to develop an integrated approach to screening and treatment of all three clinical problems.
Background: Frailty makes older adults vulnerable to adverse health outcomes and can modify pharmacokinetics and drug
exposure.
Objective: We aimed to explore the relationship between different frailty assessments and trough plasma concentrations of direct oral anticoagulants in older patients.
Methods: The frailty status of adults aged ≥ 70 years receiving regular direct oral anticoagulant medication was assessed
by four different instruments: Fried physical phenotype, Rockwood frailty index, Short Physical Performance Battery, and FRAIL scale. The two performance measures “slow gait speed” and “weak grip strength” were used to build a separate score depending on the number of positive criteria (none, one, two). For each participant, a single steady-state direct oral anticoagulant trough plasma concentration was collected, dose-normalized, and its relationship to the various frailty assessments analyzed.
Results: Forty-two participants completed the study, with most using apixaban (n = 22). Dose-normalized apixaban trough
concentrations were 2.48-fold higher in frail participants (Fried phenotype) than in robust participants (p = 0.009) and correlated positively with Fried physical phenotype (rs = 0.535, p = 0.010) and negatively with Short Physical Performance
Battery (rs = − 0.434, p = 0.044). Compared with participants who met none of the criteria “slow gait speed” and “weak
grip strength”, apixaban trough concentrations were approximately 1.9-fold higher in participants who were positive for one (p = 0.018) or two (p = 0.013) of these measures.
Conclusions: In this exploratory study, higher levels of frailty on performance-based frailty assessments were associated
with higher apixaban exposure in older adults.
Durch das Konzept von Frailty wird eine ältere Risikopopulation beschrieben, die eine erhöhte Wahrscheinlichkeit für das Auftreten negativer Gesundheitsereignisse aufweist. Aus gesellschaftlicher und auch aus individueller Sicht erscheint es erstrebenswert, die Prognose dieser Menschen durch gezielte Interventionen zu verbessern. Zwischenzeitlich liegt eine Reihe von systematischen Übersichtsarbeiten und Metaanalysen vor, die ganz unterschiedliche Interventionen vergleichen. Diese Arbeiten kommen zu dem Schluss, dass Trainingsinterventionen die besten Effekte erzielen. Gruppenangebote scheinen effektiver zu sein als Trainingsprogramme, die (teilweise) im häuslichen Setting absolviert werden. Das „case finding“ für solche Interventionen sollte mithilfe von Frailty-Instrumenten erfolgen, die auf Kraft, Ausdauer und/oder körperliche Aktivität fokussiert. Hier eignen sich insbesondere die Frailty-Kriterien nach Fried oder aber das Gehtempo und die Short Physical Performance Battery (SPPB). Ein flächendeckendes Angebot entsprechender Trainingsgruppen erscheint aus geriatrischer Sicht dringend erforderlich. Die Umsetzung erfordert jedoch einen deutlichen Ausbau bestehender Strukturen und neue Wege, um ältere Menschen mit Frailty zu erreichen.