: Background: Participatory research has become important for intervention development. Furthermore, there is a lack of training to improve communication on mental health issues in cancer care. Objective: To develop an online communication training tool for medical staff in a participatory process. Method: A participatory research team (PRT, n = 11 medical staff and cancer patients) discussed psychosocial stressors and challenging communicative situations in eight moderated focus group discussions. Based on the results and the empirical literature, training materials were created and evaluated by the PRT. All focus group discussions were audio-recorded, transcribed verbatim, and analyzed qualitatively. Results: Qualitative analysis identified "information exchange" and "responding to emotions" as the most crucial communication strategies. Training should focus on how to communicate with cancer patients with depression and anxiety. Conclusion: In the low-threshold online intervention, participants learn how to convey information appropriately and respond to patients' emotional stress through model conversations between patients and practitioners. Zusammenfassung: Theoretischer Hintergrund: Partizipative Forschung ist f & uuml;r die Entwicklung von Interventionen wichtig. Daneben gibt es nur wenige Kommunikationstrainings & uuml;ber psychische Probleme bei Krebspatient_innen. Fragestellung: Ziel war die partizipative Entwicklung eines Online-Kommunikationstrainings f & uuml;r medizinisches Personal. Methode: Ein partizipatives Forschungsteam (PRT, n = 11 medizinische Fachkr & auml;fte und Krebspatient_innen) diskutierte in acht moderierten Fokusgruppendiskussionen psychosoziale Stressoren und herausfordernde Kommunikationssituationen. Auf Grundlage der Ergebnisse und der empirischen Literatur wurden Schulungsmaterialien erstellt und anschlie ss end erneut vom PRT evaluiert. Alle Diskussionen wurden audiografiert, verbatim transkribiert und qualitativ analysiert. Ergebnisse: Der qualitativen Analyse zufolge waren die Kommunikationsstrategien & bdquo;Informationsaustausch" und & bdquo;auf Emotionen eingehen" am wichtigsten. Ein Training sollte sich darauf konzentrieren, wie man mit depressiven und & auml;ngstlichen Krebspatient_innen kommuniziert. Schlussfolgerung: In der niedrigschwelligen Online-Intervention lernen Teilnehmer_innen anhand von Modellgespr & auml;chen zwischen Patient_innen und Behandler_innen Informationen ad & auml;quat zu vermitteln und auf die emotionalen Belastungen der Patient_innen einzugehen.

BACKGROUND:Loneliness can have profound health consequences for cancer patients, yet age-related patterns of loneliness remain inconsistent and mainly cross-sectional. We describe loneliness in young (<40 years), middle-aged (40-65 years), and older (≥65 years) patients over time during early cancer survivorship, identify biopsychosocial risk factors for loneliness, and examine its impact on health outcomes across age groups. METHODS:This multicenter prospective longitudinal study included cancer patients within two months of diagnosis and at 6-, 12-, and 18-month follow-ups. Loneliness was measured using the UCLA loneliness scale. Generalized-linear-mixed-models examined changes over time. Mixed-effects regression models identified risk factors for loneliness and examined the predictive value of loneliness on physical and mental health outcomes over time. RESULTS:In total, 994 patients (53% men, 60.5 years) were included in this analysis. Older patients reported lowest and most stable loneliness over time (15-20%), whereas middle-aged (19-31%) and young (25-38%) patients reported higher loneliness values, particularly shortly after diagnosis. Risk factors for being lonely included lower social support, absence of a partner, lower socioeconomic status, advanced disease, and greater comorbidity burden (all p < 0.05). Higher loneliness at diagnosis predicted mental disorders and psychosocial care needs at follow-ups, in addition to distinct age-specific relationships of reduced physical and mental QoL for middle-aged, and non-adherence for older patients (all p < 0.05). CONCLUSION:Loneliness is common during early cancer survivorship, particularly among young and middle-aged patients shortly after cancer diagnosis. Age-related mechanisms, vulnerabilities and consequences of loneliness may inform clinical communication, e.g. about non-adherence or recommendation of tailored psychosocial support. TRIAL REGISTRATION:This study was registered in the International Clinical Trials Registry (NCT04620564, https://clinicaltrials.gov/).

OBJECTIVE:Fragmentation within the healthcare system is a challenge to continuous care provision internationally. Patients with age-associated and chronic diseases with complex care requirements often face barriers to managing their care. Patient navigation interventions aim to support patients with their individual care coordination needs. Here, we investigate the feasibility and efficacy of a patient-oriented navigation program for stroke and lung cancer patients. METHODS:Results of two randomized controlled trials that were part of a mixed methods study, are reported. 170 stroke patients and 64 lung cancer patients were randomized. The intervention group received the personal navigation for one year. The control group received a brochure with regional support offers. Two primary feasibility criteria were analyzed: uptake of initial navigation meetings (>70%) and drop-out of intervention (<40%). Further, we investigated the program's efficacy regarding satisfaction and trust with medical care. RESULTS:Both primary feasibility criteria were met as 96.9% (95%CI: 90.8%-100.0%) of lung cancer patients and 86.9% (95%CI: 79.9%-94.1%) of stroke patients of the intervention group received a first navigation meeting and only 10.5% (95%CI: 0%-24.3%) of lung cancer patients and 8.6% (7 of 81 patients, 95%CI: 2.5%-14.8%) of stroke patients dropped out of the study. Overall, no significantly higher satisfaction levels with medical care were detected for the intervention group with control group as reference (lung cancer: OR (95%CI): 1.40 (0.44-4.46); stroke: OR (95%CI): 1.16 (0.64-2.11), values > 1 indicate higher satisfaction in intervention group). In exploratory subgroup analyses, stroke patients without partner in the intervention group reported higher levels of trust with medical care compared to controls (OR (95%CI): 3.53 (1.14-10.09)). CONCLUSION:Our findings suggest feasibility of a patient-oriented navigation program focused on care coordination and support with social care questions regarding its uptake. PRACTICE IMPLICATIONS:Identifying patient subgroups with higher navigational need should be focussed on for efficient program implementation.

This guideline for the diagnosis and treatment of squamous-cell carcinoma and adenocarcinoma of the esophagus was developed and managed by the German Guideline Program in Oncology (GGPO) of the Association of the Scientific Medical Societies in Germany (AWMF), German Cancer Society (DKG), and German Cancer Aid (DKH). The guideline commission comprised multidisciplinary experts from various professional associations and organizations involved in the management of esophageal cancer, as well as a patient representative. Quality of the evidence is presented using Oxford evidence-based medicine system, and recommendations were graded in a formal consensus process using a recommendation grading scheme.

Viele Krebserkrankte erleben im Krankheitsverlauf psychische Belastungen, die die Lebensqualität und die Behandlung nachhaltig beeinträchtigen können. Die Identifikation und Versorgung dieser psychosozialen Belastungen ist eine wichtige Aufgabe einer multiprofessionellen onkologischen Versorgung. Zur Identifikation haben sich psychoonkologische Screenings als effizient erwiesen. Das Ziel der vorliegenden Arbeit liegt in der Beschreibung der bestehenden Screeningprozesse (inkl. der verwendeten Messinstrumente) und der Behandlungspfade. Es wurde eine Sichtung relevanter deutschsprachiger Literatur zum Thema psychoonkologisches Screening durchgeführt, um aktuelle Erkenntnisse und Praxisansätze zusammenzufassen. Ein Screening auf psychische Belastung ist sinnvoll, um bedarfsgerecht und zielorientiert psychoonkologisch versorgen zu können. Eine flächendeckende Umsetzung psychoonkologischer Screenings in der onkologischen Versorgung steht jedoch noch aus. Es finden sich erhebliche Unterschiede hinsichtlich der Durchführung, Verantwortlichkeit, Datenintegration und Auswertung des psychoonkologischen Screenings. Psychoonkologische Screenings gehören zum Standard einer multiprofessionellen patientenzentrierten onkologischen Versorgung. Für ein flächendeckendes Screening sind klare Strukturen, geregelte Abläufe und Behandlungspfade und transparente Verantwortlichkeiten sowie ausreichende personelle Ressourcen unabdingbar. Nur so ist eine bestmögliche und ganzheitliche Versorgung von onkologischen Patient*innen zu gewährleisten.

Eine Reihe von Trainings sind bereits zur Stärkung der Kommunikation zwischen medizinischem Fachpersonal und Krebspatient*innen entwickelt worden. Allerdings ist der Zugang zu den Trainings teilweise mit Hürden, wie Zeitaufwand oder mangelnder Akkreditierung verbunden. Ziel des hier entwickelten Kommunikationstrainings war es, kurze praxisorientierte Trainingseinheiten online zur Verfügung zu stellen, um so denjenigen Behandler*innen ein zusätzliches Angebot zu machen, die diese Modalität bevorzugen. Die Trainingsentwicklung erfolgte im Team von Behandler*innen, Patient*innen und Forscher*innen.

Background: Patients with cancer suffer from cancer-and treatment-specific, psychosocial and care-related stress and mental disturbances. Methods: This article is based on pertinent publications retrieved by a search in PubMed, as well as on the German clinical practice guideline on psycho-oncology. Results: The most common mental disorders in cancer patients are anxiety disorders, affective disorders, and adjustment disorders. The point prevalence of any mental disorder in patients with cancer is 20% to 50%. Common disease-associated psychological symptoms include distress (a non-specific experience of emotional discomfort), demoralization, and fear of cancer recurrence or progression. These can cause severe suffering even if they do not meet the diagnostic criteria for any particular mental disorder. Mental comorbidity is associated with complications of treatment, lesser adherence to treatment, lower quality of life, and increased mortality. Psychotherapeutic interventions are effective and show moderate to large effects in current meta-analyses with respect to the reduction of anxiety and depression and improvement in quality of life. These effects persist over several months of follow-up. The empirical evidence for psychopharmacotherapy in cancer patients is limited. Psychopharmacological treatment should be integrated into an overall psycho-oncological treatment plan. Conclusion: A large body of evidence shows that mental comorbidity is common among cancer patients and harmful to them. Psychotherapeutic interventions lessen the symptoms of mental distur-bances and improve quality of life. Nonetheless, despite improvements in recent years, there are remaining barriers to the adequate provision of psychosocial care.

Abstract Purpose Due to the growing number of new oncological diagnosis and the accompanying psychosocial burden, needs-based psycho-oncological care is important. Adequate planning of psycho-oncological support services is therefore becoming increasingly important. In order to better implement psycho-oncological support services, we investigate psychosocial distress, perceived need and utilization of psycho-oncological support offers in newly diagnosed cancer patients. Methods Based on a multicenter prospective study, we assessed the cross-sectional data on psychosocial distress, perceived need and utilization of psycho- social support in patients with different tumor entities within 2 months after initial diagnosis. Psychosocial distress was assessed using the Distress Thermometer (DT). Results Of 1,003 eligible patients who completed the questionnaire (53.0% men, mean age 60.3 years) 39.7% (n = 390) showed above-threshold psychosocial stress (DT: scores ≥ 5) and 21% (n = 207) indicated a perceived need for psycho- social support. 13.5% (n = 136) showed both, psychosocial distress and perceived need for psycho- social support. 15.2% (n = 150) out of all participating patients used psycho-oncology service, 60.7% (n = 597) were willing to accept such an offer. Women were significantly more likely to be psychosocially distressed and to express a need for support. They were also significantly more likely to seek and be willing to accept psycho- social support. Conclusion Although most patients would accept a psycho- social service, regardless of whether there is psychosocial distress or a need is perceived, the actual utilization was relatively low. It can therefore be assumed that barriers, e.g. structural or personal ones, prevent access. These should be investigated in more detail in future studies.

OBJECTIVE:This study aimed to assess the experiences and expectations regarding advance directives among patients with gynecological cancer, with an additional focus on patients with migration backgrounds. METHODS:An anonymous, self-administered questionnaire comprising 38 multiple-choice questions on advance directives was distributed online and in paper form from May 2019 to April 2021 across Germany. Participants included women diagnosed with various gynecological tumors. The survey was available in German, Turkish, Arabic, and Russian to capture culture-specific differences. RESULTS:Out of 718 participants, 355 (49.4%) reported having an advance directive. Patients with an advance directive were significantly older (64.5 years) compared to those without (56.0 years, p < .0001). Advanced tumor stage (Fédération Internationale de Gynécologie et d'Obstétrique III and IV) was not significantly associated with having an advance directive (OR 0.82, 95% CI 0.49 to 1.35, p = .43). Compared to women with ovarian/fallopian tube/peritoneal cancer, those with cervical cancer (OR 0.7, 95% CI 0.35 to 1.39, p = .31), endometrial cancer (OR 0.43, 95% CI 0.16 to 1.12, p = .09), and vulvar cancer (OR 0.58, 95% CI 0.16 to 2.04, p = .39) were less likely to have an advance directive. A total of 56.8% of patients believed their family doctor should initiate end-of-life care discussions. Among the 18.2% of women with migration backgrounds, there was a lower likelihood of having an advance directive (OR 0.61, 95% CI 0.35 to 1.03, p = .07) and a significantly higher desire for information and documentation about advance directives in their native language (p = .0001). A total of 330 (48.4%) patients reported that a conversation with their physician would be the most important way to receive information about end-of-life care and advanced directives. CONCLUSIONS:This study highlights a substantial need for enhanced information and proactive discussions about end-of-life care among patients with gynecological malignancies, particularly emphasizing the pivotal role of family doctors in these conversations. Notably, women with migration backgrounds are disproportionately disadvantaged in accessing and understanding advance directives, underscoring the urgent need for information and documents about advance directives in their native language. It is therefore recommended that the medical team routinely and proactively address these relevant topics in discussions with their patients and that clinical guidelines should also reflect this.

Background:Organizing healthcare becomes ever more complex for people with chronic conditions. Additionally, a distinct separation of inpatient and outpatient care makes it even more difficult to provide coordinated and continuous care across sectors in Germany. Our interview study aimed to identify difficulties and unmet needs along the care continuum of patients with lung cancer and stroke in Germany. Methods:Data were collected by qualitative interviews. A total of 40 participants with lung cancer (n=20) and stroke (n=20) were interviewed in the metropolitan region of Berlin, Germany. Data were interpreted through thematic analysis. Results:We identified five main categories of difficulties and unmet needs: 1. Bureaucracy, 2. Unmet information needs, 3. Feeling left alone, 4. Difficulties and unmet needs in healthcare institution settings, and 5. Psychological and emotional stress. Results of our study show a high overlap between the experienced difficulties of both groups of patients. These include, in particular, bureaucratic obstacles, the lack of detailed information, poor coordination of care, and the feeling of being alone with the disease and its consequences. Conclusion:Patients with complex care trajectories seem to have great need for coordinative, social, bureaucratic, and emotional support and these support topics are largely independent of the index disease. Hence, our research suggests that support offers focusing on social and coordination needs do not have to be disease-specific but can rather cover general needs of people with complex care situations.

Angehörige von an Krebs Erkrankten erleben oft ein vergleichbares Ausmaß an Belastungen wie die Erkrankten. Auch sie werden mit Herausforderungen der Krebserkrankung und -behandlung konfrontiert. Insbesondere die Partnerschaft kann durch eine Krebserkrankung beeinträchtigt werden. Paare können sowohl positive (z. B. höhere Kohäsion, Stärke) als auch negative Herausforderungen (v. a. in der Kommunikation über belastende Themen wie Angst, Tod und Sterben) erleben. Paare zu stärken, gemeinsam die Erkrankung zu bewältigen, erhöht das Wirgefühl und die partnerschaftliche Zufriedenheit. Insbesondere die Stärkung des dyadischen Copings ist hier von großer Bedeutung. Das Dyadische Coping Inventar kann dabei helfen, die Krankheitsverarbeitung in Paarbeziehungen sowohl auf der Verhaltensebene (was tun die Partner*innen) als auch auf der kognitiven Ebene (was nehmen die Partner*innen jeweils wahr) zu erfassen. Hierbei können positive und negative Subformen sowie drei Diskrepanzmaße unterschieden werden. Der Einfluss des Copings auf verschiedene, auch krankheitsbezogene Outcomes ist belegt. Die Berücksichtigung der psychosozialen Belastungen der Angehörigen und die Einbeziehung von Angehörigen in die Versorgung sind somit von großer Bedeutung.

ABSTRACTObjectiveIndividuals with low socioeconomic status (SES) exhibit higher rates of mental disorders; however, data in oncological populations are insufficient. This study investigated the course of DSM‐5 mental disorders in cancer patients, stratified by SES, over a period of 1.5 years following initial cancer diagnosis.MethodsThis multi‐center prospective longitudinal study assessed cancer patients within two months of cancer diagnosis (t1), and at 6‐, 12‐, and 18‐month follow‐up (t2–t4) using the SCID‐5 interview for mental disorders based on DSM‐5 criteria. Chi‐square‐tests were tested for frequency changes over time. A generalized linear mixed model (GLMM) was applied with fixed effects for SES and time on mental disorders.ResultsOut of 1030 patients with a SCID‐5 at baseline (53.2% men, 60 years), 821, 719 and 654 participated at respective follow‐ups. The most common diagnoses were skin and prostate cancer. Point prevalence of mental disorders was 20.9% at baseline, decreasing to 18.2%, 14.6%, and 15.0% (t2–t4; χ2 (3) = 15.3, p = 0.002). Patients with low SES consistently showed highest prevalence rates, whereas patients with high SES showed decreasing rates of mental disorders over time, with a main effect of time (χ2 (3) = 19.9, p < 0.001) and SES (χ2 (2) = 8.8, p = 0.01) in the GLMM. Two thirds never met diagnostic criteria for a mental disorder. Sensitivity analysis among study completers (n = 592) revealed a similar pattern to the main analysis.ConclusionsCancer patients with low SES exhibit impaired coping with cancer‐related stressors, increasing their risk for mental disorders. Social disparities affect physical and mental health, possibly via health behavior or health literacy, and need to be addressed by tailored survivorship care planning.

OBJECTIVE:Family caregivers play a critical yet often overlooked role in healthcare, facing the dual challenge of providing clinical care while managing their emotional well-being. Although several studies have investigated the supportive care needs and services for caregivers of advanced cancer patients integrated into specialized palliative care inpatient units, little is known about cancer caregiver integration and support structures in German outpatient cancer care. This qualitative study addresses this gap by exploring the experiences of family caregivers in Germany, using a dyadic approach to assess their needs, identify referral strategies, and evaluate oncologists' perspectives on improving caregiver integration and support. METHODS:Thematic analysis was conducted on semi-structured interviews with 14 advanced cancer patients, 15 family caregivers, and 3 oncologists. MAXQDA software facilitated the identification of key themes and codes. RESULTS:Three interconnected themes emerged: (1) The Impact of Illness on the Dyadic Relationship, (2) Communication with Physicians and Understanding of Healthcare Information, and (3) Challenges and Preferences in Navigating Healthcare Services and Psychosocial Support. SIGNIFICANCE OF RESULTS:The findings highlight the need for enhanced support in caregiving to improve cancer care quality, emphasizing that early palliative care integration is vital for addressing caregiver needs as a core component of comprehensive cancer care. Healthcare practices should adopt personalized, proactive support strategies from diagnosis, implement regular needs assessments, and leverage digital healthcare tools to enhance the efficacy and efficiency of caregiver support.

BACKGROUND:Interventions to improve care coordination, like patient navigation programs, aim to dismantle barriers faced by patients in accessing optimal care. A variety of interventions are currently being evaluated in Germany and internationally. A key challenge of these studies, as for trials in general, is finding an effective recruitment strategy to reach the intended sample size in the targeted population. METHODS:Detailed documentation of the recruitment process was conducted as part of the process evaluation for a mixed-methods feasibility study including randomized trials and parallel cohort studies to evaluate a patient-oriented navigation program. Patients with lung cancer and stroke were actively recruited in inpatient and specialized outpatient settings in a rural and a metropolitan area in Germany between June 2021 and September 2022. Reasons for excluding or not approaching patients were documented and patients' reasons for refusal were assessed. All quantitative data were analysed in a descriptive manner. Experiences during the recruitment process were investigated through interviews with recruiting personnel and analysed through thematic analysis. RESULTS:The data from the screening and recruitment process show that 74-76.5% of stroke patients and 91-93% of lung cancer patients were eligible to take part in the study. Of these, 44-46.9% of inpatients and 73% of outpatients were actively approached for recruitment. Reasons for not approaching patients were mainly due to organizational and contextual factors. Documented reasons for patients' refusal to participate in the study included feeling overwhelmed (stroke patients) and not perceiving the study as relevant (lung cancer patients). CONCLUSIONS:The presented experiences and barriers during the recruitment process for a feasibility study of a patient navigation program provide important lessons for future planning of appropriate recruitment strategies to enrol patients with age-associated diseases. TRIAL REGISTRATION:The study was registered at the German Clinical Trials Register (DRKS-ID: DRKS00025476, Registration Date: 04/06/2021).

Background and purpose: Dyadic coping (DC) considers the perception of both the individual and their partner’s coping behavior and influences various health outcomes. Given the paucity of research investigating the course of DC after a cancer diagnosis, we explored longitudinal data to find statistically distinct trajectories of DC and to characterize and predict those based on medical, psychological and sociodemographic characteristics. Materials and methods: In this prospective, multicenter study, we assessed patients with primary solid tumors at four measurement points using validated self-report questionnaires: first within 8 weeks of diagnosis, then at 6-month intervals. We measured DC using the Dyadic Coping Inventory (DCI). Clusters were identified via a feature-based clustering approach, characterized with t-tests and chi-squared tests and predicted with multinomial logistic regression. Results and interpretation: We analyzed data from 418 patients in a partnership (mean age 61 years, 55.3% men, 84.8% married). Most prevalent cancers were prostate cancer (25.6%), skin cancer (17.5%) and breast cancer (16.3%). One cluster (33.5%) reported a stable high trajectory of coping behavior, indicating good coping behavior. It had the following characteristics: male (62.9%), regularly employed (57.9%), prostate cancer (34.3%) and childless (27.1%). The remaining sample contained a cluster with increasing coping behavior (34.7%) and another with decreasing coping behavior (31.8%). Lack of regular employment, having children and generalized anxiety are significantly associated with worsening coping behavior. This study is one of the first to examine DC trajectories in a large sample of cancer patients in the early phase after diagnosis. It is essential to understand markers such as psychological stress or family and work-related issues to optimize clinical and psycho-oncological outcomes and facilitate the support or maintenance of couple-related disease management in the long term.

ABSTRACT Background Socioeconomic status' (SES) impact on distress during cancer survivorship has been insufficiently studied, although the consequences of low SES can be cumulative and adversely impact a person's ability to access resources required for improved health and quality of life. Patients and Methods We conducted a prospective study involving newly diagnosed patients within 2 months of diagnosis (t1), and at 6‐, 12‐, and 18‐month follow‐up (t2–t4) using the Distress Thermometer (DT). Generalized Linear Mixed Models (GLMM) were used to test for changes in distress over time, with fixed effects of time, SES, and age. Results Out of 1702 eligible patients, 965 completed the baseline DT (53% men, 60.5 years); 779, 681, and 626 participated at follow‐ups. Out of 554 completers, 9% were chronically distressed, while 40.8% were never distressed. Distress decreased in 21.3%, increased in 11.0%, and 17.8% fluctuated over time. Low‐SES patients consistently had the highest rates of distress. Distress scores and the frequency of distress (DT ≥ 5) decreased over time in all SES and age groups: For DT mean scores, GLMM revealed a significant effect of time (χ2(3) = 72.0, p < 0.001), but not of SES (χ2(2) = 5.9, p = 0.052). For frequency of distress, there was a main effect of time (χ2(3) = 41.4, p < 0.001) and SES (χ2(2) = 15.5, p < 0.001). Younger patients (< 65 years) consistently experienced more distress than older patients (≥ 65 years). For DT mean scores, GLMM showed an effect of time (χ2(3) = 72.1, p < 0.001) and age (χ2(1) = 66.2, p < 0.001). Similarly, for frequency of distress we found an effect of time (χ2(3) = 41.7, p < 0.001) and age (χ2(1) = 52.8, p < 0.001). Conclusion Effective psychosocial interventions require a customized approach to decrease distress in vulnerable groups. Trial Registration This study was registered in the International Clinical Trials Registry (NCT04620564, https://clinicaltrials.gov/)

Stigmatization in cancer patients leads to poorer health-related outcomes. The effect of socioeconomic status (SES) on stigmatization has not been investigated. We therefore aim to investigate, which differences in stigmatization in cancer patients regarding SES exist up to one year after diagnosis and which medical and demographic characteristics are associated with stigmatization. Patients with different solid cancer diagnoses were assessed within two months after diagnosis (t1) and at a 12-month follow-up (t2). Stigmatization was assessed using the Social Impact Scale (SIS), which comprises four dimensions: isolation, rejection, shame and financial insecurity. An SIS-total score can be computed. Bivariate and multiple regression analysis were performed. Six hundred-eighty patients completed the assessments (mean age 60.4; 51.2