In  Anbetracht  der  steigenden  Zahl  an  älteren  und  multimorbiden  Patienten  in  Deutschland und  den  westlichen  Nationen  stellt  die  Geriatrie  eine  der  größten  gesundheitspolitischen, ökonomischen  und  sozialen  Herausforderungen  unserer  Gesellschaft  dar.  Die  Implementie‐ rung  der  Geriatrie  in  die  universitäre  Lehre  von  Studierenden  der  Medizin  ist  daher  essentiell.  Dabei  ist  die  Handhabung  geeigneter  geriatrischer  Screeningverfahren  im  klinischen Alltag  ein  wichtiger  Bestandteil,  um  Abläufe  zu  vereinfachen,  Diagnostik  und  Therapie  zu  individualisieren und Kosten zu reduzieren.   Das  geriatrische  Assessment  in  Form  des  STEP‐Assessments  (Standardisiertes  evidenzbasiertes  präventives  Assessment  älterer  Menschen  in  der  medizinischen  Primäreversorgung)  ist ein  solches  Screeningverfahren,  welches  im  Rahmen  des  Blockpraktikums  Allgemeinmedizin an  der  Universität  Leipzig  von  Medizinstudierenden  durchgeführt  wird.  Es  erfasst  ein breites Spektrum an Bedürfnissen in vielen unterschiedlichen Lebensbereichen  geriatrischer Patienten  und  scheint  daher  besonders  für  die  Sensibilisierung  von  Studierenden  der  Medizin  für die  Komplexität  der  Geriatrie  geeignet  zu  sein.  Zur  Verbesserung  der Auswertungsquantität und ‐genauigkeit  des  geriatrischen  Assessments  wurde  eine  Checkliste  als  strukturierende Interpretationshilfe  installiert.  In  dieser  Studie  wird  der  Effekt  dieser  Checkliste  im  Vergleich zweier Kohorten von Studierenden untersucht. Als weitere Indikatoren für die mögliche Verbesserung  der  Auswertungsquantität  und ‐genauigkeit  wurde  die  Benotung  des  Blockpraktikums, sowie für die Zufriedenheit der Studierenden mit dem  Blockpraktikum eine Evaluation herangezogen.  Bei  statistisch  belegter  Vergleichbarkeit  der  Patientenkohorten,  fanden  wir  bei  nahrzu  allen  STEP‐Themen  mehr  Dokumentation  durch  die  Studierenden,  denen  die  Checkliste  als  Interpretationshilfe  vorlag.  Durch  diese  checklistenassoziierte  Steigerung  der  Dokumentationsquantität  und  ‐genauigkeit  ließ  sich  eine  signifikante  Verbesserung  der  Noten  der  Studierenden  mit  Checkliste  gegenüber  derer  ohne  Checkliste  verbuchen.  Die  Analyse  der Evaluation zeigte jedoch, dass die Studierenden mit Checkliste mit dem Blockpraktikum nicht signifikant zufriedener waren.  In  der  Gegenüberstellung  der  Auswertungen  des  geriatrischen  Assessments  durch  die  Studierenden  mit  der  aktuellen  Fachliteratur  und  Leitlinien  stellte  sich  stellenweise  eine  Diskrepanz  dar.  Die  von  den  Studierenden  empfohlenen  Diagnostik‐  oder  Therapieansätze  waren zwar stets medizinisch korrekt, entsprachen jedoch nicht immer den empfohlenen klinischen Leitlinien.  Es  stellt  sich  die  Frage,  ob  dies  bei  noch  nicht  abgeschlossenem  Studium  von  den Studierenden  erwartet  werden  kann,  oder  ob  indikationsgerechte  und  zielführende  Vorschläge ausreichend sind.   Die  Ergebnisse  dieser  Untersuchung  zeigen,  dass  ein  Screeninginstrument  mit  der  Komplexität  eines  STEP‐Assessments  erst  in  Kombination  mit  einer  strukturierenden  Interpretations‐ hilfe  in  Form  einer  Checkliste  von  den  Studierenden  sachgerecht  gehandhabt  werden  kann.  Es  konnte  eine  Steigerung  der  Auswertungsgenauigkeit  sowie ‐quantität  gesehen  werden, was  zu  der  Vermutung  führt,  dass  dies  ebenfalls  zu  einer  Erhöhung  des  Lernerfolges  bei  den Studierenden  gereichte.  Eine  Verbesserung  der  Art  der  Implementierung  der  Checkliste  und deren  gesonderte Evaluation  wären wünschenswert,  um  die  Zufriedenheit  der  Studierenden mit der Checkliste messbar zu machen.  Ein Rückschluss dieser Ergebnisse auf bereits spezialisierte  Allgemeinmediziner  oder  Geriater  liegt  nahe  und  sollte  in  einer  weiteren  Studie  eingehend untersucht werden.

Background: Older patients are vulnerable to chemotherapy-related toxicity (CRT). Therefore we evaluated screening tools in their power to predict CRT. Methods: Patients with cancer aged ≥65 years completed three screening questionnaires (G8, optimised G8 and Cancer and Ageing Research Group (CARG). Additionally, Comprehensive geriatric assessment (CGA) for verification of supportive care needs was undertaken on patients with impaired G8 scores. During chemotherapy treatment patients were assessed, capturing grade 0–5 CRT as defined by NCI CTCAE 4. Results: 104 patients with non-haematological cancers were included at three study sites. Median age was 73 years (range 65–85). Onco-geriatric screening detected 74% as impaired using G8 and optimised G8 questionnaires and 86% using CARG screening. Grade 3–5 toxicity affected 64.4% of all patients. G8 (OR 0.3 95% CI [0.1;1.0]) and optimised G8 (OR 0.4 95% CI [0.1; 1.5]) did not reliably predict CRT, whereas screening with CARG demonstrated a strong prediction of severe CRT: OR 4.2, 95% CI [1.1, 15.9]. CGA was undertaken on 66 patients, revealing deficiencies in nutritional (83%) and functional-status (54%) and occurrence of relevant comorbidity (53%). Conclusion: The CARG tool could be useful for predicting CRT. CGA showed clinically relevant supportive care needs in patients with a positive G8 screening.:1. Einleitung ..................................................................................................................................... - 3 - 1.1 Epidemiologie der Krebserkrankungen bei älteren Patienten .................................................. - 4 - 1.2 Herausforderungen der geriatrischen Onkologie ..................................................................... - 5 - 1.3 Status Quo ................................................................................................................................. - 7 - 1.4 Geriatrisches Assessment (GA)................................................................................................ - 11 - 1.6 Geriatrisches Screening ........................................................................................................... - 13 - 1.5 Chemotherapie assoziierte Toxizität ....................................................................................... - 15 - 2 Ableitung der Studienrationale ...................................................................................................... - 17 - 3 Publikationsmanuskript .................................................................................................................. - 18 - 4 Zusammenfassung der Arbeit ........................................................................................................ - 26 - 5 Literaturverzeichnis der Einleitung ................................................................................................ - 29 - 6 Anlagen ........................................................................................................................................... - 35 - 7 Abkürzungsverzeichnis ................................................................................................................... - 52 - 8 Erklärung über die eigenständige Abfassung der Arbeit ................................................................ - 53 - 9 Lebenslauf – David Immanuel Kotzerke ......................................................................................... - 54 - 10 Spezifizierung des eigenen Beitrages ........................................................................................... - 56 - 11 Danksagungen .............................................................................................................................. - 58 -

INTRODUÇÃO: Delirium é um problema médico frequente em idosos e está potencialmente associado a desfechos desfavoráveis, como prolongamento da hospitalização, declínio funcional e cognitivo, e maior mortalidade. Contudo, considerando que, geralmente, ocorre em situações de grande complexidade clínica, o efeito ajustado de delirium e seus subtipos motores sobre o prognóstico de pacientes acometidos ainda não foi suficientemente explorado. OBJETIVOS: Investigar em idosos agudamente enfermos hospitalizados: (1) a associação independente entre ocorrência de delirium e tempo para óbito intra-hospitalar, e em 12 meses de seguimento; (2) a associação independente entre subtipos motores de delirium e tempo para óbito intra-hospitalar, e em 12 meses de seguimento. MÉTODOS: Estudo de coorte prospectivo realizado em uma enfermaria de geriatria de um hospital universitário terciário, em São Paulo, Brasil. Foram incluídas internações de pacientes agudamente enfermos, com idade igual ou superior a 60 anos, hospitalizados entre junho de 2009 e maio de 2014. Delirium foi detectado pelo Confusion Assessment Method e classificado de acordo com o subtipo motor em hipoativo, hiperativo, ou misto. Os desfechos primários foram tempo para óbito intra-hospitalar, e tempo para óbito em 12 meses (para a amostra que recebeu alta). Os pacientes foram avaliados na admissão seguindo modelo de avaliação geriátrica ampla que incluiu variáveis sociodemográficas, clínicas, funcionais, cognitivas, e laboratoriais. Informações adicionais sobre a hospitalização foram registradas na alta ou no óbito. As análises multivariadas foram realizadas por meio de modelos de riscos proporcionais de Cox. Foi examinada a presença de modificação do efeito de delirium sobre os desfechos por análises de interação com outros fatores clínicos. RESULTADOS: Incluímos 1.034 hospitalizações, com uma média de idade de 80 anos. Na amostra geral, 61% eram mulheres, e 35% tinham demência. A mortalidade intra-hospitalar foi de 22%, com uma mortalidade cumulativa de 44% em 12 meses. Delirium ocorreu em 52% das internações, e o subtipo motor predominante foi o hipoativo (53%). Nas hospitalizações com delirium, 32% dos idosos faleceram no hospital, com uma taxa de óbitos cumulativa de 59% em 12 meses. Verificamos que delirium teve associação independente com tempo até óbito intra-hospitalar (HR=1,63 IC95%=1,11-2,40), porém não encontramos associação estatisticamente significante com sobrevida em 12 meses após ajuste para as covariáveis selecionadas. Constatamos, ainda, que os subtipos hipoativo e misto se associaram independentemente com o desfecho intra-hospitalar (HR=1,87 IC95%=1,24-2,83; HR=1,65 IC95%=1,022,67), mas não houve associação estatisticamente significante com o desfecho em 12 meses. O efeito de delirium sobre o tempo até óbito intrahospitalar não foi modificado de modo significativo por sua interação com idade, câncer, desnutrição, ou valores de albumina sérica. CONCLUSÕES: Um terço dos idosos agudamente enfermos internados que tiveram delirium faleceu ainda no hospital. Delirium se associou a menor tempo de sobrevida intra-hospitalar, mesmo após ajuste para características clínicas coexistentes. Além disso, profissionais da saúde devem ter especial atenção com os subtipos hipoativo e misto de delirium, que também se associaram independentemente com maior mortalidade intra-hospitalar em idosos / BACKGROUND: Delirium in older adults is common and potentially associated with unfavorable outcomes, such as longer hospital stay, functional and cognitive decline, and higher mortality. However, given that it usually occurs in a context of great clinical complexity, the adjusted effect of delirium and its motor subtypes on the prognosis of affected patients has not been sufficiently explored. OBJECTIVES: To investigate in acutely ill hospitalized older adults: (1) the independent association between delirium and time to death in the hospital, and in a 12-month follow-up; (2) the independent association between delirium motor subtype and time to death in the hospital, and in a 12-month follow-up. METHODS: Prospective cohort study completed in a geriatric ward of a tertiary university hospital, in Sao Paulo, Brazil. We included admissions of acutely ill patients aged 60 years and over, who were hospitalized from June 2009 to May 2014. Delirium was detected using the Confusion Assessment Method and classified according to its motor subtype in hypoactive, hyperactive, or mixed. Primary outcomes were time to death in the hospital, and time to death in 12 months (for the discharged sample). Patients were evaluated at admission according to a comprehensive geriatric assessment model that included socio-demographic, clinical, functional, cognitive, and laboratory variables. Further clinical data were documented upon death or discharge. Multivariate analyses were performed using Cox proportional hazards models. We investigated the potential modification of the effect of delirium on outcomes including an interaction term between delirium and other clinical variables. RESULTS: We included 1,034 hospitalizations, with a mean age of 80 years. Overall, 61% were women, and 35% had dementia. The proportion of in-hospital deaths was of 22%, with a cumulative mortality of 44% in 12 months. Delirium ensued in 52% of the admissions, and the predominant motor subtype was hypoactive (53%). In-hospital death occurred in 32% of the cases with delirium, while cumulative 12-month mortality reached 59% in this group. We verified that delirium was independently associated with time to in-hospital death (HR=1.63 95%CI=1.11-2.40), but did not find statistically significant association with 12month survival after adjusting for selected covariates. We additionally found that hypoactive and mixed motor subtypes were independently associated with in-hospital death (HR=1.87 95%CI=1.24-2.83; HR=1.65 95%CI=1.02-2.67), but there were no significant associations with 12-month mortality. The effect of delirium on time to in-hospital death was not significantly modified by its interaction with age, cancer, malnutrition, or serum albumin levels. CONCLUSIONS: One third of acutely ill hospitalized older adults who suffered delirium died in the hospital. Delirium was associated with decreased survival in the hospital, even after adjusting for coexistent clinical characteristics. In addition, health care providers should be attentive for the hypoactive and mixed subtypes of delirium, as they were also independently associated with poorer in-hospital outcomes in older adults

Dado o acelerado processo de envelhecimento populacional vivenciado no Brasil e no mundo, é importante identificar quais as melhores maneiras de avaliar a saúde da pessoa idosa inserida na comunidade ou institucionalizada. Neste sentido, a Organização Mundial de Saúde preconiza a avaliação desta população por meio da condição funcional. Diferentes instrumentos se propõem a este fim, seja evidenciando o desempenho de atividades ou capacidade funcional, por métodos aferido ou referido. No entanto, existe grande diferença entre estas possíveis maneiras de avaliação da pessoa idosa e poucos estudos que abordem este tema. Objetivo: comparar a avaliação de atividades básicas de vida diária (ABVD) por meio do desempenho referido e aferido em pessoas idosas residentes na comunidade. Método: Estudo transversal que avaliou 40 idosos que realizavam tratamento ou acompanhamento médico em dois ambulatórios (clínica médica e ortopedia) no município de Londrina (PR). Esta amostra foi avaliada frente desempenho funcional por meio da Medida de Independência Funcional (MIF) e o desempenho referido foi verificado a partir da utilização de um questionário padronizado. Ao todo, 12 atividades básicas de vida diária foram avaliadas por ambos os métodos. Para possibilitar a comparação entre as respostas obtidas em cada instrumento, houve um processo de categorização no qual cada idoso era classificado como independente; tendo dificuldade ou utilizando adaptação para realizar a atividade; ou necessitando de ajuda. Foi utilizado o teste do coeficiente de Kappa e teste de correlação de Spearman para comparar a concordância entre os métodos de avaliação da condição funcional. Resultados: Os idosos residentes na comunidade apresentavam média etária de 71,6 anos (IC 95% 72,8;79,4) e maior proporção de mulheres (52,5) e a maioria dos participantes não apresenta comprometimento da função cognitiva. Dentre as atividades avaliadas, aquelas relacionadas ao uso e acesso ao vaso sanitário foram as que a presentaram menor concordância. Já locomoção, alimentação, controle de fezes, banho e vestir-se são aquelas mais comparáveis. Pela comparação entre os métodos de avaliação foi possível observar que a avaliação de modo aferido evidencia indivíduos com menor nível funcional frente a avaliação autorreferida das mesmas atividades. As dificuldades aferidas e referidas estiveram relacionadas com a condição de saúde do idoso avaliado, sendo que idosos provindos do ambulatório ortopédico apresentavam maior comprometimento de atividades que comprometiam membros superiores ou inferiores. Foi possível concluir que a avaliação de ABVD utilizando desempenho referido ou aferido apresenta respostas similares para maioria das atividades avaliadas, com grau de concordância substancial. No entanto, as respostas obtidas pelo método de avaliação autorreferido devem ser interpretadas com cautela, principalmente quando da avaliação do uso e acesso ao vaso sanitário. Os métodos de avaliação avaliados são complementares e quando possível ambos devem ser aplicados para avaliação funcional de pessoas idosas. / About the accelerated ageing process experienced in Brazil and the world, it is important to identify the best ways to check the health of the older persons inserted in the community. In this sense, the World Health Organization indicates the assessment of functional condition as good option to evaluate this population. Different instruments are proposed and it can be done by the assessment of capacity or performance, by measured or (self) reported methods. However, these methods are different and there are few studies that address this issue. Objective: To compare the evaluation of activities of daily living (ADL) by reported or measured performance in older adults living in community. Methods: Cross-sectional study that evaluated 40 subjects who were undergoing treatment or medical care at two clinics (generical medicine and orthopedics) in Londrina (PR). This sample was evaluated from the functional performance through the Functional Independence Measure (FIM) and reported performance was observed from the use of a standardized questionnaire. Twelve ADL were assessed by both methods. To enable a comparison of obtained responses with each instrument, the subjects were classified as independent; with difficulty or using adaptation to perform the activity; or who needing help. We used the Kappa coefficient test to compare the agreement among the methods to assess functional condition. Results: community-dwelling older adults had a mean age of 71.6 years (95% CI 72.8; 79.4) and higher proportion of women (52.5) and most of the participants does not have impaired cognitive function. Among the activities evaluated, those related to the use and access to the toilet showed the least agreement. Already locomotion, feeding, control stool, bathing and dressing are those more comparable. In the comparison process, it was observed that the older adults had lower functional level when the assessment is made by measured performance against reported assessment of the same activities. The measured and reported difficulties were related to the health condition of the evaluated elderly, and older persons in treatment of orthopedic clinic had greater commitment in activities involving the arms or legs, structures in rehabilitation process. When we evaluated community-dwelling elderly, there was a higher level of agreement between measured functional condition and reported performance. We concluded that the evaluation of ABVD using measured or reported performance shows similar responses to most of the activities evaluated, with substantial degree of agreement. However, the responses obtained by self-reported assessment method should be interpreted with caution, especially when assessing the use of and access to toilet. The methods of this evaluation are complementary and it is a better option when both can be applied for functional assessment of elderly.

This study explores the relationship between living arrangement and psychological wellbeing in retired elderly individuals living in Yancheng, Jiangsu (PR China). Data on mode of residence, socio-economic background, daily activities, and intergenerational dynamics were collected from 200 subjects, and their potential correlations with depression (assessed via the Geriatric Depression Scale Short Version) were analyzed. Univariate as well as logistic regression confirmed mode of residence as a significant predictor of depression in this group. The following depression odds ratios associated with each mode of residence were derived via logistic regression: 1) nuclear household, i.e. living with a spouse only ¨C 1 [reference category], 2) multigenerational households in which a spouse is not present ¨C 4.341, 3) multigenerational households in which a spouse is present ¨C 0.781, and 4) living alone ¨C 3.018. Based on these ratios, we conclude that the traditional model of intergenerational coresidence is not, in itself, associated with less depression. Rather, it is the presence of a sharing spousal in a household (whether single or multigenerational) that protects against elderly depression. Other predictors of depression identified in backward logistic regression included presence of a chronic illness and self assessed wealth status. Additionally, a number of psychosocial variables were identified as independently correlated with depression, but were subsequently selected out by multivariate analysis. These included: educational background, religious affiliation, membership in an organization, attitude toward aging, and family status. Based on this study, we believe that efforts to promote mental wellbeing among today¡¯s Chinese elders should be directed toward psychosocial factors that are modifiable (education, building supportive social networks etc.) rather than insisting on the traditional ideal of multigenerational living and dependence on filial piety.

Introduction: Stroke is associated with a high prevalence of dysphagia in the elderly population. Hence, dysphagia evaluation and management are key issues in stroke rehabilitation. The McGill Ingestive Skills Assessment (MISA) is a recently developed mealtime observational tool aimed at evaluating the functional aspects of the oral phase of ingestion. Objective: To determine the discriminative validity of the MISA by assessing known/extreme groups of elderly individuals presenting with stroke, who have been admitted to an acute-care-hospital or a rehabilitation center. Participants were allocated to one of two groups: 1) individuals with stroke and no dysphagia, who are on a regular diet and 2) individuals with stroke and dysphagia, who are permitted only purees. Methods: Participants were evaluated with the MISA and a comprehensive chart review was conducted. Analysis: Groups were compared on socio-demographic and clinical characteristics. Univariate tests were performed to test the significance of between-group differences. Conclusion and significance: The results of the study are satisfactory, and enhance the clinical usefulness of the tool for dysphagia management. These results also support future studies addressing the responsiveness of the MISA.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2005. / Härtill 4 uppsatser.

Diss. (sammanfattning) Linköping : Linköpings universitet, 2006. / Härtill 4 uppsatser.

Diss. (sammanfattning) Umeå : Umeå universitet, 2006. / Härtill 4 uppsatser.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2006. / Härtill 4 uppsatser.