Die stationäre medizinische Rehabilitation durch die deutsche Rentenversicherung hat einen großen Anteil an der Behandlung kranker Menschen. Bundesweit gibt es etwa 60 000 stationäre Behandlungsplätze, davon etwa 17500 in den knapp 100 eigenen Rehazentren der Deutschen Rentenversicherung. In diesem Versorgungsbereich gibt es seit Jahren eine der konsequentesten Entwicklungen in der Qualitätssicherung. Dies erklärt sich dadurch, dass die Rentenversicherung sich nicht nur als Kostenträger, sondern auch als Leistungserbringer versteht und sich daher in den von ihr belegten Kliniken auch für die Qualität der erbrachten Behandlung direkt verantwortlich fühlt. Hinzu kommt, dass die medizinische Rehabilitation spätestens seit der Gesundheitsreform im Jahre 1997 unter besonderem Rechtfertigungsdruck und neuen Wettbewerbsbedingungen steht. Des Weiteren verpflichtet auch § 20 SGB IX die Leistungserbringer, ein Qualitätsmanagement sicherzustellen, das zielgerichtet und systematisch die Qualität der Versorgung gewährleistet und kontinuierlich verbessert.

BACKGROUND:Activities of daily living, play a key role in the measurement of functional health as defined by the International Classification of Functioning, Disability and Health (ICF) and in prevention and treatment of mental or somatic illnesses. From a clinical context it is important to discriminate between basic "activities of daily living, ADL", "intentional activities of daily living, IADL", and "recreational activities of daily living, RADL". While ADL and IADL have gained much attention in dementia, the elderly, or severe somatic illnesses, there is a lack of research on RADL, which are important in depression, anxiety, or other neurotic disorders.SUBJECTS AND METHODS:154 unselected inpatients of a department of behavioral and psychosomatic medicine filled in the "Check List of Recreational Activities" to assess the rates and profiles of RADL.RESULTS:Patients reported on average 19.3 (s.d. 7.0) activities (range 4 - 40), i.e. males 21.3 (s.d. 6.5, 9 - 34) and females 18.9 (s.d. 7.1, 4 - 40). Most frequent RADL were passive and unspecific activities like "watching tv" (93.4%). Least frequent were activities which need special skills or preparation like "horse back riding" (0.7%). Low rates were also found for activities which are in the centre of inpatient occupational therapy like "ceramics" (4.7%) or "silk-painting" (2.6%). There are differences between sexes but not in respect to age (18 to 60), sick leave and unemployment, or diagnostic status. When patients were asked what they would like to do in the future, the same activity profile emerged as when looking at what they had done in the last monthCONCLUSION:The data give a reference profile for recreational activities, help to define what can be considered a normal frequency and spectrum of RADL, and, by this, can guide therapeutic interventions.

In an investigation of benzodiazepine (BDZ) prescription patterns, psychiatrists in private practice were found to exhibit “therapist non-compliance” with regard to general medical recommendations for BDZ use. The findings indicate that BDZ prescriptions in general (53% among patients treated with psychotropics) as well as long-term treatment of patients (37%) are quite common among private practice psychiatrists. BDZ treatment is not restricted to “minor psychiatric disorders”, and contrary to the guidelines, even patients with substance dependence are not excluded. A positive association was found for BDZ use and patients' self-reported symtoms and health complaints, the number of other medications prescribed and age. In a discussion of therapist noncompliance it is proposed that this may be a consequence of a symptom-based treatment model, individual health concepts, the doctor-patient relationship and physician's cost-benefit analysis. Thus, psychiatrists' non-compliance may reflect to some extent a case-oriented treatment rationale.

Background. Depressive syndromes not fulfilling the criteria for specified disorders (subthreshold depression, SD) may be clinically important. We aimed to study SD in old and very old age, in comparison with subjects with no depressive symptoms (NDS) and subjects with major depression (MD). Methods. A community-based random sample of 516 subjects, age 70 to 100 years and over, stratified by age and sex, was examined. All participants were investigated by psychiatrists and by geriatricians independently. Results. In 16·5% ( N = 85) of the study subjects SD was identified. Study subjects with SD had, similarly to the subjects with MD, significantly more somatic diagnoses and used more somatic as well as psychotropic medications than the subjects with NDS. Self-ratings and observer ratings of depression indicated that SD was a milder depressive state than MD. Conclusions. Compared with MD, SD is probably a milder form of depression. The increased use of psychotropic medications indicates that at least a portion of these individuals have a disorder requiring treatment. One of the characteristics of SD is co-morbidity with somatic illnesses and physical disability.

BACKGROUND Previous studies have found a relationship between single indicators of ventilatory capacity and measures of cognitive function, but have not addressed dementia specifically. This study examined the relationship between different indicators of ventilatory capacity and dementia, diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, controlling for important confounding factors. METHODS Cross-sectional data on participants (n = 437) of the Berlin Aging Study (BASE), which are representative of former West Berlin's living population aged 70 years and older, were analyzed. Ventilatory capacity was measured by spirometry as peak expiratory flow rate (PEF-R), forced expiratory volume in 1 second (FEV-1), maximal expiratory flow at 50% of forced vital capacity (MEF50%FVC), and maximal expiratory flow at 25% of forced vital capacity (MEF25%FVC). Odds ratios (OR) for dementia associated with ventilatory capacity were obtained by logistic regression, adjusting for age, gender, education, ApoE4 status, chronic obstructive pulmonary disease, smoking, heart failure, visual and auditory functioning, grip strength, and former physical activity. RESULTS Separate analyses for PEF-R, FEV-1, MEF50%FVC, and MEF25%FVC revealed significantly increased odds for dementia among subjects in the lowest compared with the best functioning group in ventilatory testing. The OR associated with PEF-R > or = 2 l/s was found to be 20.4 (confidence interval [CI] 5.1-82.7). For FEV-1, MEF50%FVC, and MEF25%FVC ORs of 7.5 (CI 2.1-27.9), 4.3 (CI 1.5-12.5), and 4.7 (CI 1.3-17) were obtained, respectively. CONCLUSIONS Ventilatory capacity, measured by spirometry in a representative sample of very elderly people, is cross-sectionally related to dementia. Taking evidence from longitudinal studies into account, this result suggests that decreased respiratory function may increase the risk for dementia, independent from already known risk factors.

Recent studies revealed that subthreshold depression (or "subclinical" or "subsyndromal" depression) can have clinical validity because it is related to dysfunction and disability and is a risk factor for major depression. However, none of these studies focused on old age. Therefore, one aim of the psychiatric part of the multidisciplinary Berlin Aging Study (BASE) was also to detect milder forms of psychopathological syndromes, especially subthreshold depression, compared with specified forms such as major depression and dysthymia according to the DSM-III-R. The present evaluation shows that subthreshold depression can be characterized in 2 ways: firstly, as a quantitatively minor variant of depression or st depression-like state with fewer symptoms or with less continuity; and secondly, as qualitatively different from major depression with fewer suicidal thoughts or feelings of guilt or worthlessness, while worries about health and weariness of living occur with a similar frequency. Copyright (C) 2000 by W.B. Saunders Company.

We investigated time use of persons assigned to seven groups on the basis of psychiatric diagnoses: (a) no dementia or depression symptoms, (b) individuals with dementia symptoms but no DSM-III-R-diagnosis, (c) individuals with dementia according to DSM-III-R, (d) individuals with depression symptoms but no diagnosis, (e) individuals with depression not further specified (NFS), (f) individuals with depression according to DSM-III-R, and (g) individuals with symptoms of both dementia and depression. In general, time-use parameters were similar across the groups. As expected, however, we found differences in specific dimensions. Demented and depressed individuals differed from others with respect to the duration of passive phases and receptive leisure. Instrumental activities, active leisure, length of the waking day, and time spent alone were indicators with differential validity regarding dementia diagnoses--partly even after controlling for physical morbidity. Moreover, we were able to differentiate between dementia and depression on the basis of instrumental activities after controlling for physical morbidity.

Zusammenfassung Wir haben die Zeitverwendung von Personen in 7 aus der psychiatrischen Diagnostik resultierenden Gruppen verglichen: a) Probanden ohne dementielle oder depressive Symptome, b) Probanden mit einzelnen Demenz-Symptomen ohne Krankheitswert, c) Probanden mit Demenz nach DSM-III-R, d) Probanden mit depressiven Symptomen ohne Krankheitswert, e) Probanden mit Depression NNB, f) Probanden mit Depression nach DSM-III-R und g) Probanden, bei denen es (mindestens) Symptome beider Erkrankungen gab. Generell erwies sich die Gestaltung des Tages in den Gruppen als ähnlich. Wie erwartet konnten jedoch in spezifischen Dimensionen Unterschiede ausgemacht werden. Demente und depressive Probanden unterschieden sich hinsichtlich der Dauer von Ruhezeiten und der „rezeptiven Freizeit” gleichsinnig von den übrigen Personen. Instrumentelle Aktivitäten, aktive Freizeit, Ta- geslänge und allein verbrachte Zeit besaßen differentielle Validität hinsichtlich Demenz-Diagnosen, z.T. auch nach Berücksichtigung körperlicher Morbidität. Die Berücksichtigung körperlicher Morbidität ermöglichte auch, auf der Basis der instrumentellen Aktivitäten Demenz- und Depressions-Diagnosen voneinander zu differenzieren.

Background. Long-term low-dosage dependence on benzodiazepines is traditionally explained by withdrawal symptoms. Previous research has not given much attention to reports that suggest that many patients oppose stopping benzodiazepines long before withdrawal symptoms have developed. This study investigates the scope of and factors associated with this pre-withdrawal treatment insistence.Methods. Patients receiving long-term low-dosage benzodiazepines in primary care were asked to take a drug-holiday of at least 3 weeks. Sociodemographic, medication, morbidity and attitudinal variables were assessed in addition to the GPs' perceptions of their patients.Results. Two-thirds of the patients rejected the drug-holiday proposal. Patients who refused a drug-holiday were less educated and were using a higher percentage of long-acting benzodiazepines than patients who accepted the drug-holiday proposal. Those who refused were seen by their GPs as being more complaining, harder to satisfy and less co-operative.Conclusions. These results provide evidence for drug-seeking or craving behaviour of patients who receive low-dosage benzodiazepine prescriptions. A major problem in benzodiazepine withdrawal occurs before the withdrawal programme has even begun. These data show that benzodiazepine low-dosage dependence should be considered a real form of dependence.

In the Berlin Aging Study (BASE) an age and gender stratified sample of 516 persons aged 70 to over 100 was assessed by means of the semi-structured GMS-A interview, the CES-D-self-rating scale and the Hamiltion-Depression-observer-rating scale. Prevalence rates were 4.8% for Major Depression, 9.1% for all DSM III-R specified depressive disorders and 26.9% of subthreshold depression was included. There was no increase in prevalence rates with age but an increase in scores on the self rating CES-D. The prevalence rates for DSM III-R specified depression in females was 10.3% and almost double that of men (5.6%). Depressed persons do not show significant cognitive impairment as measured with the MMSE in comparison to controls. As compared to the total sample higher prevalence rates of overall depression were seen in persons with multimorbidity (36.8%) and lower rates in married persons. 13.2% of the elderly talked about feeling tired with life, 7.9% had thoughts about death and 1.2% reported suicidal ideation, which was closely linked to depressive disorders. In 44% of depressed cases undertreatment was observed. Only 6% got Antidepressants but 40% benzodiazepines.

Zusammenfassung In der Berliner Altersstudie (BASE) wurde eine nach Alter und Geschlecht geschichtete Stichprobe von 516 Studienteilnehmern im Alter von 70 bis über 100 Jahren untersucht. Zur Diagnostik von depressiven Erkrankungen wurde neben den Fremd- und Selbstratingskalen (HAMD und CES-D) das halbstrukturierte GMS-A-Interview eingesetzt, auf dessen Basis Diagnosen nach DSM III-R erstellt wurden. Es fand sich eine Prävalenz von 9,1% für alle nach DSM III-R spezifizierten depressiven Störungen, wovon 4,8% Major Depression waren. Bei Hinzunahme von nach klinischer Einschätzung krankheitswertigen Depressionen, welche die Kriterien für eine spezifizierte DSM III-R-Diagnose jedoch nicht erfüllten, steigt die Depressionsprävalenz auf 26,9% an. Die Häufigkeiten in den verschiedenen Altersgruppen unterscheiden sich mit Ausnahme bei der CES-D nicht signifikant. Die Depressionsprävalenz für spezifizierte DSM III-R-Diagnosen ist bei Frauen mit 10,3% etwa doppelt so hoch wie bei Männern (5,6%). Depressive Patienten zeigen im Vergleich zu Kontrollpersonen keine signifikant schlechteren Werte im MMSE. Eine signifikant erhöhte Depressionsprävalenz findet sich im Vergleich zur Gesamtstichprobe bei Personen mit Multimorbidität (36,8%). Verheiratete Studienteilnehmer zeigen seltener eine depressive Erkrankung (14,9%). 13,2% der alten Menschen sprechen von Lebensüberdruß, 7,9% äußern einen Todeswunsch und 1,2% Suizidgedanken. Es besteht eine enge Beziehung zwischen Suizidalität und depressiven Erkrankungen. Im Bezug auf die Behandlung depressiver Störungen fand sich in 44% eine unzureichende Therapie. 6% der depressiven Studienteilnehmer wurden mit Antidepressiva behandelt, während 40% nur Benzodiazepine bekamen.

In the Berlin Aging Study (BASE) an age and gender stratified sample of 516 persons aged 70 to over 100 was assessed by means of the semi-structured GMS-A interview the CES-D-self-rating scale and the Hamiltion-Depression-observer-rating scale. Prevalence rates were 4,8% for Major Depression, 9,1% for all DSM III-R specified depressive disorders and 26,9% of subthreshold depression was included. There was no increase in prevalence rates with age but an increase in scores on the self rating CES-D. The prevalence rates for DSM III-R specified depression in females was 10,3% and almost double that of men (5,6%). Depressed persons do not show significant cognitive impairment as measured with the MMSE in comparison to controls. As compared to the total sample higher prevalence rates of overall depression were seen in persons with multimorbidity (36,8%) and lower rates in married persons. 13,2% of the elderly talked about feeling tired with life, 7,9% had thoughts about death and 1,2% reported suicidal ideation, which was closely linked to depressive disorders,ln 44% of depressed cases undertreatment was observed. Only 6% got Antidepressants but 40% benzodiazepines.