Background: Around 800,000 older people live in approximately 16,500 nursing and old people's homes in Germany and this number will continue to rise due to demographic change. Visual impairment and eye diseases in need of treatment are among the most common yet most neglected health problems in this vulnerable population. This article summarizes the current state of ophthalmological care for nursing home residents in Germany, the barriers involved and the potential contribution of novel tele-ophthalmological care models to closing this care gap. Material and methods: Narrative review based on a selective literature search (PubMed, Google Scholar, professional society documents) on ophthalmological care of institutionalized older people with particular focus on the German OVIS and S & Auml;VIP studies, the international literature on prevalence and care models in nursing homes and both published reports on the TOVIS study (TeleOphthalmologische Versorgung In Seniorenheimen). Results: The OVIS study (2017; n = 600; 32 homes) found an ophthalmological result requiring treatment in 61% of residents, most frequently cataract (53%), age-related macular degeneration (AMD, 39%) and glaucoma (11% suspected); the last ophthalmologist visit occurred on average 4 years earlier. Comparable deficits are described across numerous other countries. The TOVIS pilot study (2023; n = 109 of 139 enrolled residents) tested a telemedical shared-eye-care model in which trained nonmedical personnel performed on-site examinations while ophthalmologists provided remote assessment. A vision-relevant cataract was found in 48.5%, typical AMD lesions in 34.1% and inadequately fitted eyeglasses in 60.6%; only 31.2% of the examined residents were aware of their diagnosis. At 6-month follow-up only 14 of 52 residents (26.9%) with a referral recommendation actually attended a specialist appointment, despite over 80% rating the tele-examination positively. Conclusion: Ophthalmological care in German nursing homes has been insufficient for years, a pattern that is consistently mirrored across numerous other healthcare systems in the international literature. Tele-ophthalmological shared-eye-care models such as TOVIS are feasible and well accepted but do not by themselves solve the aftercare problem. A substantial gap remains between diagnosis and actual specialist treatment, which requires structured appointment management, transport and accompaniment solutions and closer collaboration between nursing staff, primary care and ophthalmology.
Geriatrics and neurosurgery have several points of contact, which require a close cooperation. In this context, diseases frequently affecting old people include chronic subdural hematomas, benign and malignant brain tumors, normal pressure hydrocephalus, spinal compression syndromes, spinal nerve root and peripheral nerve affections. In the case of absolute indications for surgery (e.g., symptomatic subdural hematoma, paraparesis or tetraparesis due to compression of the myelon), no alternative conservative treatment option is available to prevent death or irreversible damage. Such interventions should not be withheld from geriatric patients, as long as there is a realistic chance to prolong their lives with a satisfactory quality and if they truly wish this intervention. With respect to relative indications for surgery (e.g., pain without paresis as a consequence of an affection of a nerve root or a peripheral nerve), surgery should only be considered once all options for conservative therapy have been exhausted.
Background: The care of older people is often characterized by cross-sectoral support and care arrangements in which health and social services are closely intertwined. As such arrangements frequently fail in practice, analyzing complex care trajectories is important to foster more user-centered care systems. To date, suitable research designs for this purpose are limited. Objective: Drawing on established approaches to case study methodology and the authors' own empirical preliminary work, this paper presents a qualitative case study design to empirically reconstruct care trajectories. Material and methods: The paper outlines the methodology of a multilevel multiple case study in which care trajectories are conceptualized as case constellations. These emerge from interactive practices involving the individuals concerned as well as professional and informal caregivers (microlevel), they are embedded in organizations and in local and professional networks (mesolevel) and are shaped by broader contextual conditions (macrolevel). The design combines interviews, documents, socio-spatial and network analyses, evaluated using reflexive thematic analysis and cross-case generalization. Results: Biographical, professional and institutional perspectives are systematically integrated. Through the multiperspective reconstruction of actual care practices, context-dependent conditions of care delivery can be identified. Conclusion: Multilevel multiple case studies offer new opportunities for analyzing care settings. They place high demands on field access, data integration and research ethics. Case studies expand the methodological toolkit for health services research.
