BACKGROUND:In this study (NCT04333303), we investigated whether a complex advance care planning (ACP) intervention improves care consistency with care preferences in nursing home residents. METHODS:Forty-four German nursing homes were randomly assigned to an ACP intervention addressing the individual, institutional, and regional levels or to a control group (no intervention). The hospitalization rate over an observation period of 12 months (primary outcome) was analyzed as a surrogate for care consistency with care preferences at the nursing home level. Secondary outcomes comprised process-related and clinical parameters, including care consistency with care preferences (analysis level: residents/ nursing homes). Outcomes were evaluated by means of Poisson and logistic regression models with incidence rate ratios (IRR) and odds ratios (OR) as effect estimators in an intention-to-treat analysis. RESULTS:Of 44 nursing homes, 23 received the intervention. The hospitalization rate did not differ between the two groups (IRR 1.0; 95% CI: [0.97; 1.1]) but declined to a similar extent in both during the COVID-19 pandemic. The consistency of care with care preferences was similar in both groups as well (OR 0.9 [0.4; 1.9]). The predefined exploratory analysis suggests that care consistency with care preferences was more likely in the 6 out of 23 nursing homes that met predefined adherence criteria (OR 1.9 [0.7; 5.3]). Written emergency plans were significantly more common in the intervention group (IRR 11.6 [8.2; 16.4]), and even more so in adherent nursing homes (IRR 30.1 [15.7; 57.6]). CONCLUSION:The intervention did not permeate sufficiently, especially due to the COVID-19 pandemic that may, in addition, have masked intrinsic shortcomings of the intervention. Thus, this trial does not allow a conclusive assessment of whether or not the intervention can promote care consistency with care preferences. However, exploratory analyses indicate that successful institutional implementation in conjunction with individual ACP conversations may increase care consistency with care preferences.

OBJECTIVES:To investigate the change in anticholinergic burden over a 5 year period in relation to the health characteristics of older adults. STUDY DESIGN:Using data from the MultiCare Cohort Study (2008-2013), a prospective observational cohort study based on patient data from 158 general practices SETTING: Primary care in Germany. PARTICIPANTS:3189 multimorbid adults aged 65 to 85 years PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the change in the anticholinergic burden score (ACB) over a 5 year period. The ACB was defined as the dependent variable and was calculated by including all anticholinergic drugs prescribed to participants during the study period. Independent variables included age, sex, education (according to CASMIN), depressiveness (GDS), cognitive function (LDST), quality of life (EQ5D-3L) and the number of diseases weighted by severity. We performed multilevel mixed-effects multivariable linear regression analyses. RESULTS:A total of 7068 observations were analysed during three follow-ups. The mean age of the participants was 74.4±5.2 years and 59.3% were female. The mean ACB score was 1.5±1.7 at baseline and did not change significantly over time. In contrast, a higher severity-weighted number of diseases (coefficient: 0.08, 95% CI: 0.05/0.10, p<0.001), a higher number of depressive symptoms (0.04, 0.004/0.08, p=0.030), poorer cognitive function (-0.03 to -0.06/-0.001, p=0.044) and poorer health-related quality of life (-0.05 to -0.08/-0.01, p=0.006) were associated with an increasing ACB score over time. CONCLUSIONS:Our results show that anticholinergic prescribing increases despite the deteriorating health status of older adults, which may lead to higher hospitalisation and mortality rates. New practice recommendations for general practitioners may be helpful in raising their awareness of cumulative ACB and enabling them to discontinue or reduce the dose of some anticholinergics where possible. However, further research is needed to assess the impact of our findings on prescribing behaviour in primary care. TRIAL REGISTRATION NUMBER:ISRCTN89818205.

BACKGROUND:Strategies to counteract the impending and in some places already existing shortage of general practitioners (GPs) are being discussed in Germany. One approach could be to establish interprofessional teams in GP practices by integrating physician assistants (PAs). QUESTION:Can GPs imagine employing a PA in their practice and if so, under what conditions? METHODS:In March/April 2023, about 5,000 GPs in North Rhine-Westphalia (NRW), who work in a region with a care level of < 100 %, and about 1,000 GPs from Saxony-Anhalt were asked to take part in an online-based survey. Simultaneously, semi-structured preliminary interviews (one online focus group with four participants, seven individual interviews) were conducted with GPs from NRW. RESULTS:290 GPs participated in the survey (response rate approx. 5 %). Of these, 46.3 % expressed interest in employing a PA in their practice. A majority of 60 % considered assignments such as conducting an open consultation for uncomplicated respiratory tract infections or vaccination consultations to be delegable. As many as 21.9 % would be willing to pay a PA more than 3,500 euro gross monthly salary (based on a full-time position) (8.7 % more than 4,000 euro), while 38.4 % stated that they could not currently afford the cost of employing a PA. The qualitative results underline these findings. One of the respondents' conditions for the employment of a PA was to abolish the quarterly budget limits for GPs. DISCUSSION:Many GPs already express their interest and willingness to both employ PAs and to delegate medical tasks to them - in spite of unanswered questions and, possibly, by necessity. About a fifth of the participants can even imagine paying from their own budget the same gross salary that PAs employed by hospitals are paid. Reliable clarification of feasibility, safety and cost-effectiveness of the use of PAs as well as effects on the quality of treatment in primary care should be a priority for health policy actors. TAKE-HOME MESSAGE:From the GP's point of view, the integration of PAs into GP-centred care in terms of an interprofessional team practice has got potential. At the same time, the question of financial feasibility is still unsettled.

Background/Objectives: Obesity and depression, in conjunction with multimorbidity, are interconnected conditions increasingly managed in general practitioner (GP) settings, yet these associations remain insufficiently studied in older patients. This study investigates the prevalence of depression across different body mass index (BMI) classes and includes age and gender differences in multimorbid older patients, offering a novel perspective on subgroup-specific patterns. Further the agreement between GP depression diagnoses and the Geriatric Depression Scale (GDS) is studied and patient-specific factors that may affect the agreement are explored, aiming to improve future diagnostics for vulnerable subgroups. Methods: Data were provided by the baseline assessment of the MultiCare Study, a prospective multicenter observational cohort of multimorbid patients aged 65+ years recruited from 158 GP practices across eight study centers in Germany. Data from 2568 study participants were analyzed based on GP-coded International Classification of Diseases (ICD) diagnoses, structured GP questionnaires, and patient questionnaires. Assessments included data on the BMI and depression (15 item version of the GDS). Agreement between GP diagnoses of depression and GDS assessment was measured using Cohen’s kappa. Four logistic regression models were used to examine the effects of patient-specific factors on the agreement of depression diagnosis (match or mismatch). Results: GPs diagnosed depression in 17.3% of cases, compared to the detection of depressive symptoms in 12.4% of the patients by GDS (cut-off ≥ 6 points). The highest prevalence rates were observed in patients with obesity class III (25.0% by GP; 21.7% by GDS). Women were significantly more likely to receive a depression diagnosis by a GP across most BMI classes (except obesity classes II and III). The detection of depressive symptoms by GDS was significantly more prevalent in older multimorbid obese patients (≥75 years), except for patients with obesity class III. The overall agreement between GP diagnosis and GDS assessment was weak (κ = 0.156, p < 0.001). The highest agreement was found for people with obesity class III (κ = 0.256, p < 0.05). Factors associated with a True Positive depression diagnosis (match by both GDS and GP) were female gender (odds ratio (OR) = 1.83, p < 0.05), widowhood (OR = 2.43, p < 0.01), limited daily living skills (OR = 3.14, p < 0.001), and a higher level of education (OR = 2.48, p < 0.01). A significantly lower likelihood of a False Negative depression diagnosis was found for patients with obesity class III. Conclusions: This study highlights the significant prevalence of depression among multimorbid older adults across different BMI classes, particularly in those with obesity class III. The weak diagnostic agreement between GP diagnosis and GDS assessment suggests a need for improved diagnostic practices in primary care. Implementing standardized screening tools and fostering collaboration with mental health specialists could enhance the identification and management of depression in this vulnerable population.

BACKGROUND:In the future, an increase in health care needs in the elderly is expected. Reports on unmet care needs of the oldest old with cognitive disorders are pending. This study aims at exploring unmet needs in the oldest old primary care patients with mild cognitive impairment (MCI) and dementia. Furthermore, the association between sociodemographic and clinical factors and unmet needs ought to be analyzed.METHODS:Based on the study "Needs, Health Service Use, Costs and Health-Related Quality of Life in a Large Sample of Oldest-Old Primary Care Patients (85+)" (AgeQualiDe), 749 patients (unimpaired, MCI, and dementia) aged 85 years and older, their relatives (n = 421), and general practitioners (GPs) (n = 607) were assessed. Descriptive, inferential, and regression analyses were run.RESULTS:Most unmet needs were observed in dementia patients, although needs were less frequently rated as unmet by dementia patients themselves as compared to relatives and GPs. Unmet needs were associated with MCI and dementia; other risk factors were age, education, and marital status.CONCLUSION:This study provides first data on unmet needs according to different perceptions in the elderly with MCI and dementia in Germany. Need assessments should be part of medical examinations to ensure a high-quality health care in the elderly.

Hintergrund In Deutschland werden Strategien diskutiert, um den Mangel an Hausärzt*innen (HÄ) zu kompensieren. Ein Konzept kann die Etablierung hausärztlicher Teampraxen durch die Integration von Physician Assistants (PAs) sein. Fragestellung Können sich HÄ die Anstellung einer/s PA in ihrer Praxis vorstellen und wenn ja, unter welchen Bedingungen? Methoden Im März/April 2023 wurden ca. 5.000 HÄ in Nordrhein-Westfalen, die in einer Region mit einem Versorgungsgrad < 100 % tätig sind, und ca. 1.000 HÄ in Sachsen-Anhalt um Teilnahme an einer online-basierten Fragebogenerhebung gebeten. Parallel wurden halbstrukturierte Gespräche (eine Online-Fokusgruppe mit vier Teilnehmenden, sieben Einzelinterviews) mit HÄ aus NRW geführt. Ergebnisse An der Befragung nahmen 290 HÄ teil (Rücklauf 5 %). Von diesen äußerten 46,3 % ein prinzipielles Interesse, eine/n PA in ihrer Praxis zu beschäftigen. Eine Mehrheit von 60 % erachtete Aufgaben wie das Führen einer offenen Sprechstunde für unkomplizierte Atemwegsinfekte oder Impfsprechstunden für delegierbar. Immerhin 21,9 % wären bereit, einer/m PA mehr als 3.500 Euro brutto pro Monat (bezogen auf eine Vollzeitstelle) als Gehalt zu zahlen (8,7 % mehr als 4.000 Euro), während 38,4 % angaben, sich eine/n PA aktuell nicht leisten zu können. Die Ergebnisse der qualitativen Erhebung unterstreichen diese Ergebnisse; als Bedingung für die Anstellung einer/s PA wurde u. a. eine Entbudgetierung der HÄ gefordert. Diskussion Zahlreiche HÄ äußern sich schon heute – ungeachtet offener Fragen und möglicherweise aus der Not heraus – interessiert und bereit, PAs anzustellen und ärztliche Aufgaben an diese zu delegieren. Immerhin ein Fünftel der Teilnehmenden würde ein Bruttogehalt in der Höhe zahlen, wie es stationär tätige PAs erhalten. Eine belastbare Klärung von Machbarkeit, Sicherheit, Auswirkungen auf die Behandlungsqualität sowie Wirtschaftlichkeit des Einsatzes von PAs in der primärärztlichen Versorgung sollte gesundheitspolitische Priorität erhalten. Take-Home-Message für die Praxis Die Integration von PAs in die hausärztliche Versorgung im Sinne einer interprofessionellen Teampraxis bietet aus hausärztlicher Sicht Potenzial; gleichzeitig ist vor allem die Finanzierbarkeit ungeklärt.

Introduction About 49% of the women in Germany take part in the German national mammography screening program. Reasons (not) to participate are still not well understood.Materials and methods Women were recruited from the participants of a former questionnaire study on the same issue. Considering their willingness to participate (6 yes, 2 no), level of education (6 high, 2 low) and confidence in their decision-making (6 high, 2 low), 8 women were selected and questioned in 2014 individually in problem-centered interviews. Sequences of the interview transcripts were evaluated by a multidisciplinary team using the content analysis approach.Results All 8 women had undergone mammography before. Analysis identified six overarching categories: sense of duty, autonomy, doubt, uncertainty, role of the physician, institutional setting. The women perceived screening as a chance to avoid the risk of being affected by breast cancer. Experience with breast cancer in their family or acquaintances influenced their decision. They put great emphasis on self-determination, but on the other hand they followed the advice of their trusted physician. During the screening procedure, they felt that they were exposed to an impersonal procedure that was painful.Conclusion Women tend to decide to participate in mammography screening on the emotional level. To enable women the opportunity to make an informed consent/refusal to mammography screening, physicians should discuss women's perceptions and experiences, and also provide factual information.

Nursing home residents (NHR) show high rates of polypharmacy. The HIOPP-3-iTBX study is the first cRCT on medication optimization in nursing homes (NH) in Germany. The intervention did not result in a reduction of PIM and/or antipsychotics. This analysis looks at structure quality in the HIOPP-3-iTBX study participants. Evaluation of structure quality as part of a cluster-randomized controlled intervention study. Structure quality in multiprofessional teams from n = 44 NH (n = 44 NH directors, n = 91 family doctors (FD), and n = 52 pharmacies with n = 62 pharmacists) was assessed using self-designed questionnaires at baseline. Main aspects of the questionnaires related to the qualification of participants, quality management, the medication process and size of the facilities. All completed questionnaires were included. number of PIM/antipsychotics was drawn from the baseline medication analysis in 692 NHR. Data were analyzed by descriptive statistics and mixed model logistic regression. The presence of a nurse with one of the additional qualifications pain nurse or Zertifiziertes Curriculum (Zercur) Geriatrie in the participating NH was associated with a lower risk for the prescription of PIM/antipsychotics. No association between any characteristic in the other participants at baseline was observed. The results support the known role of nursing qualification in the quality and safety of care. Further studies need to look more closely at how use is made of the additional qualifications within the multiprofessional teams. Perspectively, the results can contribute to the development of quality standards in NH in Germany.

Purpose To examine the association of sociodemographic and health-related determinants with social isolation in relation to family and friends in the oldest-old. Methods Database was the multi-center prospective AgeCoDe/AgeQualiDe cohort study assessed at follow-up wave 5 ( N = 1148; mean age 86.6 years (SD 3.0); 67% female). Social isolation was assessed using the short form of the Lubben Social Network Scale (LSNS-6). The LSNS-6 contains two sets of items establishing psychometrically separable subscales for isolation from family and friends (ranges 0–15 points), with lower scores indicating higher isolation. Cross-sectional linear (OLS) regression analyses were used to examine multivariate associations of sociodemographic and health-related determinants with social isolation from family and friends. Results Overall, n = 395 participants (34.6%) were considered socially isolated. On average, isolation was higher from friends (mean 6.0, SD 3.8) than from family (mean 8.0, SD 3.5). Regression results revealed that in relation to family, males were more socially isolated than females (β = − 0.68, 95% CI − 1.08, − 0.28). Concerning friends, increased age led to more isolation (β = − 0.12, 95% CI − 0.19, − 0.05) and functional activities of daily living to less isolation (β = 0.36, 95% CI 0.09, 0.64). Independent of the social context, depression severity was associated with more social isolation, whereas cognitive functioning was associated with less social isolation. Conclusions Different determinants unequally affect social isolation in relation to family and friends. The context of the social network should be incorporated more strongly regarding the detection and prevention of social isolation to sustain mental and physical health.

Background This project emerged from the multicenter cluster-randomized controlled BEVOR-trial investigating the effectiveness of a complex ACP intervention in German nursing homes (NHs). The trial's ACP intervention started in late summer 2020 and specifically addressed, besides the residents who were offered ACP conversations, nursing staff and aspects of nursing culture as well. The nested study reported here investigates how employees experience the implementation of ACP in their facilities two years after the program's first introduction. Methods Four focus groups exploring NH employees' subjective experience were conducted in four NHs (one each) in August and September 2022. Participants were guided to reflect upon barriers and facilitators of the ACP intervention, and invited to make suggestions for improvement. Four to nine employees of the following professional groups participated in each focus group: nurses, nursing assistants, nursing trainees, and social workers. An interprofessional team analysed transcripts of the focus groups using a structured qualitative content analysis according to Kuckartz. Results Preliminary analysis indicates a breadth in perception of ACP implementation. Commonly named changes include an increased acknowledgement of residents' care preferences, increased staff confidence with regard to handling medical emergencies, and a critical appraisal of formerly reflective approaches. Critical remarks relate to the time necessary for the implementation process, insufficient educational opportunities (for nursing assistants), emotional distress following ACP conversations in some residents, and a regret both that ACP is offered when it is too late for many residents to participate actively, and that ACP is not offered to nursing staff as well. Conclusion Implementing ACP in NHs moves respect for residents' autonomy into the centre of numerous concepts and chains of action, including approaches in medical emergencies. The facets, facilitators and barriers of cultural change identified in this study may guide future development of programs to implement ACP in nursing homes.

Zusammenfassung Einleitung Die Teilnahmerate am Mammographiescreening beträgt derzeit ca. 49 %. Über die Gründe für Frauen, am Screening teilzunehmen, ist bisher zu wenig bekannt. Material und Methoden Für eine qualitative Studie wurden aus den Teilnehmerinnen einer Fragebogenstudie zum Einfluss verschiedener Informationsbroschüren auf die Teilnahmebereitschaft 8 Frauen für Interviews ausgewählt. Die Frauen wurden nach den Kriterien Teilnahmebereitschaft (6 ja, 2 nein), Bildung (6 hoch, 2 niedrig) und Entscheidungssicherheit (6 hoch, 2 niedrig) ausgewählt und im Jahr 2014 in problemzentrierten Einzelinterviews befragt. Sequenzen der Interviewtranskripte wurden in multidisziplinären Teams inhaltsanalytisch ausgewertet. Ergebnisse Alle interviewten Frauen hatten Mammographieerfahrung. Es wurden übergreifende Themen in sechs Kategorien identifiziert: Pflichtgefühl, Autonomie, Zweifel, Unsicherheit, Arzt/Ärztin, Institution. Die Frauen sahen in der Screeningteilnahme die Chance, einer möglichen Bedrohung durch Brustkrebs zu entgehen. Erfahrungen mit Brustkrebs im Umfeld beeinflussten ihre Entscheidung. Einer selbstverantwortlichen Entscheidungsbildung wurde ein hoher Stellenwert zugesprochen, andererseits folgten sie dem Rat ihres Arztes/ihrer Ärztin. Bei der Durchführung des Screenings fühlten sie sich einer unpersönlichen und schmerzhaften Maschinerie ausgesetzt. Schlussfolgerungen Frauen treffen ihre Entscheidung, am Screening teilzunehmen oder nicht, eher auf der emotionalen Ebene. Um ihnen eine informierte Entscheidung zu ermöglichen, sollten in einem ärztlichen Gespräch neben sachlichen Informationen ihre Vorstellungen und Erfahrungen in Bezug auf das Mammographiescreening ergebnisoffen besprochen werden.

BACKGROUND:Subjective memory complaints and family history of dementia are possibly intertwined risk factors for the own subsequent dementia risk and Alzheimer's disease. However, their interaction has rarely been studied.OBJECTIVE:To study the association between subjective memory complaints and family history of dementia with regard to the own subsequent risk of dementia.METHODS:Cross-sectional and longitudinal analyses over a follow-up period of up to 13 years were conducted in a population sample of participants without dementia at baseline (n = 3,256, mean age = 79.62 years), using group comparisons and Cox proportional hazards models.RESULTS:Cross-sectionally, participants with subjective memory complaints were significantly more likely to report family history of dementia. Longitudinally, family history of dementia (FH) was significantly associated with subsequent dementia in the subjective memory complaints (SMC) group, but not in those without SMC. A relative excess risk due to interaction analysis confirmed a significant FHxSMC-interaction.CONCLUSIONS:Family history of dementia was a predictor of incident dementia in those with SMC, which can serve as an additional, clinically relevant criterion to gauge the risk of dementia in older-aged subjects with SMC with and without objective cognitive impairment.

Objective Since there is a lack of longitudinal studies in this area, our aim was to identify the determinants of persistent frequent attendance in primary care among the oldest old in Germany. Methods Longitudinal data (follow-up wave 7–9) were taken from the multicenter prospective cohort “Study on needs, health service use, costs, and health-related quality of life in a large sample of oldest-old primary care patients (85+)” (AgeQualiDe), covering primary care patients ≥ 85 years (FU7 n = 741, mean age 88.9 years (SD 2.9; 85–100)). Persistent frequent attenders of general practitioner (GP) services (the patients in the top decile of the number of GP consultations in two or more consecutive waves) were our main outcome of interest. Logistic random-effects models were used. Results Our analysis included 1,891 observations (766 individuals). Across three waves, we identified 56 persistent frequent attenders. Results of random-effects logistic regressions showed that the odds of being persistent frequent attender were higher for widowed individuals (OR = 4.57; 95% CI [1.07–19.45]). Moreover, a one-point increase in the frailty score and having one more chronic condition increased the odds of being a persistent frequent attender by 68% (OR =1.68; 95% CI [1.05–2.69]) and 23% (OR=1.23, 95% CI [1.05–1.44]), respectively. Conclusion Our study stressed the longitudinal association between frailty and widowhood as well as chronic diseases and persistent frequent attendance among the oldest old in Germany.

Objectives: Depressive symptoms and chronic pain are common among patients with multimorbidity creating a complex medical condition for both the patient and the general practitioner. Perceived social support may function as a protective measure. To examine the impact of perceived social support as a potential moderator between depressive symptoms and pain intensity and pain disability in daily activities in multimorbid patients aged 75+. Method: Data from 3,189 patients of the German longitudinal cohort study MultiCare were obtained at baseline and follow-ups during 5 years. Multilevel linear mixed-effects analyses were conducted for pain intensity (model 1) and pain disability in daily activities (model 2). The interaction term social support by depression score was included to test for moderation. Results: The interaction between social support and depressive symptoms was significantly associated with the pain intensity score 0.41 (SE=.17; 95-CI[.08;.74]) but not with the pain disability score 0.35 (SE=.19; 95-CI[-.01;.72]). Additionally, men and individuals with medium or higher educational level showed reduced pain intensity and disability scores. Pain disability scores increased with age and depressive symptoms. Increased pain scores were also found for body mass index and burden of multimorbidity. Conclusion: Perceived social support amplified the association of depressive symptoms on pain intensity and did not show a protective function. The high scores of perceived social support among the participants may point to the practice of secondary gain due to the patients immense health burden.

BACKGROUND:Depression in older adults is becoming an increasing concern. As depressive symptoms change over time, it is important to understand the determinants of change in depressive symptoms. The aim of our study is to use a longitudinal study design to explore the predictors of change, remission and incident depression in older patients with multimorbidity.METHODS:Data from the MultiCare cohort study were used. The cohort studied 3,189 multimorbid general practice patients aged 65-85. Data were collected during personal interviews. Depressive symptoms were assessed using the Geriatric Depression Scale (GDS-15). Predictors of change in depressive symptoms were determined using multivariate linear regression, while multivariate logistic regression was used to analyze predictors of remission and incident depression. Models included depressive symptoms at baseline and follow-up, socio-demographics and data on health status and social support.RESULTS:Overall, 2,746 participants with complete follow-up data were analyzed. Mean age was 74.2 years, 59.2% were female, and 11.3% were classified as depressed at baseline. Burden of multimorbidity and social support were statistically significant predictors in all regression analyses. Further predictors of change in depressive symptoms were: income, pain, nursing grade, self-rated health and self-efficacy.LIMITATIONS:The sample size for prediction of remission limited statistical certainty. Assessment of depressive symptoms using GDS-15 differs from routine clinical diagnoses of depression.CONCLUSIONS:Predictors of change in depressive symptoms in older multimorbid patients are similar to those predicting remission and incident depression, and do not seem to differ significantly from other older patient populations with depressive symptoms.

Purpose Social isolation is considered a risk factor for dementia. However, less is known about social isolation and dementia with respect to competing risk of death, particularly in the oldest-old, who are at highest risk for social isolation, dementia and mortality. Therefore, we aimed to examine these associations in a sample of oldest-old individuals. Methods Analyses were based on follow-up (FU) 5–9 of the longitudinal German study AgeCoDe/AgeQualiDe. Social isolation was assessed using the short form of the Lubben Social Network Scale (LSNS-6), with a score ≤ 12 indicating social isolation. Structured interviews were used to identify dementia cases. Competing risk analysis based on the Fine-Gray model was conducted to test the association between social isolation and incident dementia. Results Excluding participants with prevalent dementia, n = 1,161 individuals were included. Their mean age was 86.6 (SD = 3.1) years and 67.0% were female. The prevalence of social isolation was 34.7% at FU 5, 9.7% developed dementia and 36.0% died during a mean FU time of 4.3 (SD = 0.4) years. Adjusting for covariates and cumulative mortality risk, social isolation was not significantly associated with incident dementia; neither in the total sample (sHR: 1.07, 95%CI 0.65-1.76, p = 0.80), nor if stratified by sex (men: sHR: 0.71, 95%CI 0.28-1.83, p = 0.48; women: sHR: 1.39, 95%CI 0.77-2.51, p = 0.27). Conclusion In contrast to the findings of previous studies, we did not find an association between social isolation and incident dementia in the oldest-old. However, our analysis took into account the competing risk of death and the FU period was rather short. Future studies, especially with longer FU periods and more comprehensive assessment of qualitative social network characteristics (e.g., loneliness and satisfaction with social relationships) may be useful for clarification.

IntroductionSeveral lifestyle factors promote protection against Alzheimer's disease (AD) throughout a person's lifespan. Although such protective effects have been described for occupational cognitive requirements (OCR) in midlife, it is currently unknown whether they are conveyed by brain maintenance (BM), brain reserve (BR), or cognitive reserve (CR) or a combination of them.MethodsWe systematically derived hypotheses for these resilience concepts and tested them in the population-based AgeCoDe cohort and memory clinic-based AD high-risk DELCODE study. The OCR score (OCRS) was measured using job activities based on the O*NET occupational classification system. Four sets of analyses were conducted: (1) the interaction of OCR and APOE-ε4 with regard to cognitive decline (N = 2,369, AgeCoDe), (2) association with differentially shaped retrospective trajectories before the onset of dementia of the Alzheimer's type (DAT; N = 474, AgeCoDe), (3) cross-sectional interaction of the OCR and cerebrospinal fluid (CSF) AD biomarkers and brain structural measures regarding memory function (N = 873, DELCODE), and (4) cross-sectional and longitudinal association of OCR with CSF AD biomarkers and brain structural measures (N = 873, DELCODE).ResultsRegarding (1), higher OCRS was associated with a reduced association of APOE-ε4 with cognitive decline (mean follow-up = 6.03 years), consistent with CR and BR. Regarding (2), high OCRS was associated with a later onset but subsequently stronger cognitive decline in individuals converting to DAT, consistent with CR. Regarding (3), higher OCRS was associated with a weaker association of the CSF Aβ42/40 ratio and hippocampal volume with memory function, consistent with CR. Regarding (4), OCR was not associated with the levels or changes in CSF AD biomarkers (mean follow-up = 2.61 years). We found a cross-sectional, age-independent association of OCRS with some MRI markers, but no association with 1-year-change. OCR was not associated with the intracranial volume. These results are not completely consistent with those of BR or BM.DiscussionOur results support the link between OCR and CR. Promoting and seeking complex and stimulating work conditions in midlife could therefore contribute to increased resistance to pathologies in old age and might complement prevention measures aimed at reducing pathology.

AimThe aim of this study was to investigate the frequency of and the gender differences in the use of professional home care in Germany.MethodsWe used harmonized data from three large cohort studies from Germany (“Healthy Aging: Gender-specific trajectories into the latest life”; AgeDifferent.de Platform). Data were available for 5,393 older individuals (75 years and older). Mean age was 80.2 years (SD: 4.1 years), 66.6% were female. Professional homecare outcome variables were use of outpatient nursing care, paid household assistance, and meals on wheels' services. Logistic regression models were used, adjusting for important sociodemographic variables.ResultsAltogether 5.2% of older individuals used outpatient nursing care (6.2% women and 3.2% men; p < 0.001), 24.2% used paid household assistance (26.1% women and 20.5% men; p < 0.001) and 4.4% used meals on wheels' services (4.5% women and 4.0% men; p = 0.49). Regression analysis revealed that women had higher odds of using paid household assistance than men (OR = 1.48, 95% CI: [1.24–1.76]; p < 0.001), whereas they had lower odds of using meals on wheels' services (OR = 0.64, 95% CI: [0.42–0.97]; p < 0.05). No statistically significant differences in using outpatient nursing care between women and men were found (OR = 1.26, 95% CI: [0.87–1.81]; p = 0.225). Further, the use of home care was mainly associated with health-related variables (e.g., stroke, Parkinson's disease) and walking impairments.ConclusionsOur study showed that gender differences exist in using paid household assistance and in culinary dependency. For example, meals on wheels' services are of great importance (e.g., for individuals living alone or for individuals with low social support). Gender differences were not identified regarding outpatient nursing care. Use of professional home care services may contribute to maintaining autonomy and independence in old age.

Abstract Background According to recent legislation, facilitated advance care planning (ACP) for nursing home (NH) residents is covered by German sickness funds. However, the effects of ACP on patient-relevant outcomes have not been studied in Germany yet. This study investigates whether implementing a complex regional ACP intervention improves care consistency with care preferences in NH residents. Methods This is a parallel-group cluster-randomized controlled trial (cRCT) with 48 NHs (≈ 3840 resident beds) between 09/2019 and 02/2023. The intervention group will receive a complex, regional ACP intervention aiming at sustainable systems redesign at all levels (individual, institutional, regional). The intervention comprises comprehensive training of ACP facilitators, implementation of reliable ACP processes, organizational development in the NH and other relevant institutions of the regional healthcare system, and education of health professionals caring for the residents. Control group NHs will deliver care as usual. Primary outcome is the hospitalization rate during the 12-months observation period. Secondary outcomes include the rate of residents whose preferences were known and honored in potentially life-threatening events, hospital days, index treatments like resuscitation and artificial ventilation, advance directives, quality of life, psychological burden on bereaved families, and costs of care. The NHs will provide anonymous, aggregated data of all their residents on the primary outcome and several secondary outcomes (data collection 1). For residents who have given informed consent, we will evaluate care consistency with care preferences and further secondary outcomes, based on chart reviews and short interviews with residents, surrogates, and carers (data collection 2). Process evaluation will aim to explain barriers and facilitators, economic evaluation the cost implications. Discussion This study has the potential for high-quality evidence on the effects of a complex regional ACP intervention on NH residents, their families and surrogates, NH staff, and health care utilization in Germany. It is the first cRCT investigating a comprehensive regional ACP intervention that aims at improving patient-relevant clinical outcomes, addressing and educating multiple institutions and health care providers, besides qualification of ACP facilitators. Thereby, it can generate evidence on the potential of ACP to effectively promote patient-centered care in the vulnerable population of frail and often chronically ill elderly. Trial registration ClinicalTrials.gov ID NCT04333303 . Registered 30 March 2020.