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Wenn in der Medizin vom demografischen Wandel gesprochen wird [1], wird zumeist von einer rasanten Zunahme der Hochaltrigen gesprochen, bei denen aufgrund der differenziellen altersassoziierten Inzidenzraten in erster Linie eine Zunahme an Demenzerkrankungen, kardiovaskulären Erkrankungen, Krebserkrankungen und allgemeiner Multimorbidität und Gebrechlichkeit zu erwarten ist [2]. Dies ist unstrittig richtig, aber nur ein Teil der Folgen des demografischen Wandels für die psychiatrische Versorgung. Diese muss weiterhin die gesamte adulte Lebensspanne im Blick haben, da sonst Versorgungsengpässe bei ohnehin vulnerablen Patienten verstärkt werden, mit Folgen für die Morbidität und Mortalität auf Bevölkerungsebene [3].
Ziel der Studie Erfassung der Strukturen zur Frühdiagnostik von Demenzen an Krankenhäusern in Deutschland.
Methodik Fragebogenerhebung.
Ergebnisse 14 % von 1758 kontaktierten Einrichtungen antworteten. 52 % berichteten über ein entsprechendes Angebot, zum großen Teil mit leitlinienorientierten Verfahren, wie Liquordiagnostik. Das Diagnosespektrum umfasste zu 46 % Demenzen und zu 41 % Diagnosen der leichten oder subjektiven kognitiven Störung.
Schlussfolgerung Leitlinienbasierte Diagnostik und Früherkennungskonzepte sind in Gedächtnisambulanzen weitgehend etabliert.
Evaluation of technology-based interventions for informal caregivers of patients with dementia
(2019)
Objective: The aim of this study was to estimate the efficacy of technology-based interventions for informal caregivers of people with dementia (PWD). Methods: PubMed, PsycINFO, and Cochrane Library databases were searched in August 2018, with no restrictions in language or publication date. Two independent reviewers identified 33 eligible randomized controlled trials (RCTs) conducting a technology-based intervention for informal carers of PWD. Meta-analyses for the outcome measures caregiver depression and caregiver burden were conducted with subgroup analyses according to mode of delivery (telephone, computer/web-based, combined interventions). To assess methodologic quality, the Cochrane risk-of-bias assessment was rated. Results: Meta-analyses revealed a small but significant postintervention effect of technology-based interventions for caregiver depression and caregiver burden. Combined interventions showed the strongest effects. Conclusion: Technology-based interventions have the potential to support informal caregivers of PWD. Because of advantages such as high flexibility and availability, technology-based interventions provide a promising alternative compared with "traditional services," e.g., those for people living in rural areas. More high-quality RCTs for specific caregiver groups are needed.
Purpose: Postoperative cognitive dysfunction (POCD) appears in up to 30% of patients suffering from postoperative delirium (POD). Both are associated with higher mortality and postoperative complications, prolonged hospital stays, and increased costs. Multi-modal models with pre-admission risk reduction counselling, perioperative monitoring, and training of multidisciplinary patient care providers have been shown to decrease the prevalence of both. The aim of our study is to understand how far those measures are known and implemented in routine care and to detect potential gaps in the current practice regarding risk communication and information flow between involved caregivers for patients at risk for POD/POCD. Patients and Methods: As part of a multicenter study, seven semi-structured focus group (FG) discussions with nurses and physicians from tertiary care hospitals (surgery, anesthesiology, and orthopedics, n=31) and general practitioners (GPs) in private practice (n=7) were performed. Transcribed discussions were analyzed using qualitative content analysis. Results: POD is present above all in the daily work of nurses, whereas physicians do not perceive it as a relevant problem. Physicians report that no regular risk assessment or risk communication was performed prior to elective surgery. Information about POD often gets lost during hand-offs and is not regularly reported in discharge letters. Thus, persisting cognitive dysfunction is often missed. The importance of standardized documentation and continuous education concerning risks, screening, and treatment was emphasized. The often-suggested pre-OP medication adjustment was seen as less important; in contrast, avoiding withdrawal was regarded as far more important. Conclusion: Altogether, it seems that standards and available best practice concepts are rarely implemented. In contrast to physicians, nurses are highly aware of delirium and ask for standardized procedures and more responsibility. Therefore, raising awareness regarding risks, screening tools, and effective preventive measures for POD/POCD seems an urgent goal. Nurses should have a central role in coordination and care of POD to prevent the risk for POCD.
Poverty and social exclusion are closely related to an increased risk for the deterioration of mental health. In 2018 approximately 19% of the German population were threatened by poverty and the associated social ostracization. Migrant groups in particular often show an increased risk for poverty and are often exposed to multiple socioeconomic stress factors depending on the context of migration, pre-migration and post-migration social factors. Numerous studies have shown that societal exclusion, precarious living conditions and the residential environment negatively affect mental health beyond the effects of pre-migration risk factors. This article provides a review and discussion on the relationship between mental health, poverty and related constructs, such as social cohesion, social capital and social exclusion in general as well as in specific risk groups, such as migrant and refugee populations.
Der demografische Wandel wird nicht nur mit einer rasanten Zunahme der Hochaltrigen einhergehen [1], was für die gerontopsychiatrische Versorgung aufgrund der altersassoziierten Inzidenzraten in erster Linie eine Zunahme an Demenzerkrankungen und Patienten mit Multimorbidität und Gebrechlichkeit bedeutet [2], sondern auch mit einer Zunahme jüngerer alter Menschen vom 65. bis 75. Lebensjahr, was für die Gerontopsychiatrie eine Zunahme der Patienten mit Abhängigkeitserkrankungen, Erkrankungen aus dem schizophrenen Formenkreis und affektiven Erkrankungen bedeutet. Soziale Faktoren werden hier mehr und mehr eine zentrale Rolle spielen, da neben der Qualität der medizinischen Versorgung insbesondere die individuelle soziale Situation der Patienten mit einer erhöhten Morbidität und Mortalität einhergehen wird [3].
The role of perceived need support from exercise professionals in improving mental health was examined in a sample of older adults, thereby validating the short Health Care Climate Questionnaire. A total of 491 older people (M = 72.68 years; SD = 5.47) attending a health exercise program participated in this study. Cronbach's alpha was found to be high (alpha = .90). Satisfaction with the exercise professional correlated moderately with the short Health Care Climate Questionnaire mean value (r = .38; p < .01). The mediator analyses yielded support for the self-determination theory process model in older adults by showing both basic need satisfaction and frustration as mediating variables between perceived autonomy support and depressive symptoms. The short Health Care Climate Questionnaire is an economical instrument for assessing basic need satisfaction provided by the exercise therapist from the participant's perspective. Furthermore, this cross-sectional study supported the link from coaching style to the satisfaction/frustration of basic psychological needs, which in turn, predicted mental health. Analyses of criterion validity suggest a revision of the construct by integrating need frustration.
Background
Postoperative delirium is a common disorder in older adults that is associated with higher morbidity and mortality, prolonged cognitive impairment, development of dementia, higher institutionalization rates, and rising healthcare costs. The probability of delirium after surgery increases with patients’ age, with pre-existing cognitive impairment, and with comorbidities, and its diagnosis and treatment is dependent on the knowledge of diagnostic criteria, risk factors, and treatment options of the medical staff. In this study, we will investigate whether a cross-sectoral and multimodal intervention for preventing delirium can reduce the prevalence of delirium and postoperative cognitive decline (POCD) in patients older than 70 years undergoing elective surgery. Additionally, we will analyze whether the intervention is cost-effective.
Methods
The study will be conducted at five medical centers (with two or three surgical departments each) in the southwest of Germany. The study employs a stepped-wedge design with cluster randomization of the medical centers. Measurements are performed at six consecutive points: preadmission, preoperative, and postoperative with daily delirium screening up to day 7 and POCD evaluations at 2, 6, and 12 months after surgery. Recruitment goals are to enroll 1500 patients older than 70 years undergoing elective operative procedures (cardiac, thoracic, vascular, proximal big joints and spine, genitourinary, gastrointestinal, and general elective surgery procedures.
Discussion
Results of the trial should form the basis of future standards for preventing delirium and POCD in surgical wards. Key aims are the improvement of patient safety and quality of life, as well as the reduction of the long-term risk of conversion to dementia. Furthermore, from an economic perspective, we expect benefits and decreased costs for hospitals, patients, and healthcare insurances.
Trial registration
German Clinical Trials Register, DRKS00013311. Registered on 10 November 2017.
Background Aversive stimuli in the environment influence human actions. This includes valence-dependent influences on action selection, e.g., increased avoidance but decreased approach behavior. However, it is yet unclear how aversive stimuli interact with complex learning and decision-making in the reward and avoidance domain. Moreover, the underlying computational mechanisms of these decision-making biases are unknown. Methods To elucidate these mechanisms, 54 healthy young male subjects performed a two-step sequential decision-making task, which allows to computationally model different aspects of learning, e.g., model-free, habitual, and model-based, goal-directed learning. We used a within-subject design, crossing task valence (reward vs. punishment learning) with emotional context (aversive vs. neutral background stimuli). We analyzed choice data, applied a computational model, and performed simulations. Results Whereas model-based learning was not affected, aversive stimuli interacted with model-free learning in a way that depended on task valence. Thus, aversive stimuli increased model-free avoidance learning but decreased model-free reward learning. The computational model confirmed this effect: the parameter lambda that indicates the influence of reward prediction errors on decision values was increased in the punishment condition but decreased in the reward condition when aversive stimuli were present. Further, by using the inferred computational parameters to simulate choice data, our effects were captured. Exploratory analyses revealed that the observed biases were associated with subclinical depressive symptoms. Conclusion Our data show that aversive environmental stimuli affect complex learning and decision-making, which depends on task valence. Further, we provide a model of the underlying computations of this affective modulation. Finally, our finding of increased decision-making biases in subjects reporting subclinical depressive symptoms matches recent reports of amplified Pavlovian influences on action selection in depression and suggests a potential vulnerability factor for mood disorders. We discuss our findings in the light of the involvement of the neuromodulators serotonin and dopamine.
Stress plays a key role in modulating addictive behavior and can cause relapse following periods of abstinence. Common effects of stress and alcohol on the dopaminergic system have been suggested, although the precise mechanisms are unclear. Here, we investigated 20 detoxified alcohol-dependent patients and 19 matched healthy controls and assessed striatal D2/D3 availability using [F-18]-fallypride positron emission tomography and stressful life events. We found a strong association between striatal D2/D3 availability and stress in patients, but not in healthy controls. Interestingly, we found increased D2/D3 receptor availability in patients with higher stress levels. This mirrors complex interactions between stress and alcohol intake in animal studies and emphasizes the importance to investigate stress exposure in neurobiological studies of addiction.