Treatment of malignant non-Hodgkin's lymphomas in elderly patients

The number of elderly patients with non-Hodgkin's lymphomas (NHL) is continuously increasing. The diagnostic and staging procedures should be carried out in elderly patients as careful as in younger patients. Furthermore, for treatment decisions geriatric assessment and the patient's preferences concerning therapy are essential and have to be considered. The treatment of indolent NHL depends on the stage of the disease and the clinical status of the patient. Most of the patients with limited indolent NHL can be treated with curative intent using localized irradiation. Treatment of patients with advanced indolent NHL is palliative. In contrast, all stages of aggressive NHL can also be treated with curative intent in elderly patients. In limited aggressive NHL standard treatment consists of polychemotherapy followed by involved field irradiation. Standard treatment of advanced aggressive NHL is polychemotherapy with cyclophosphamide, adriamycin, vincristine and prednisone (CHOP). The goal for the near future is to improve perspectives for elderly patients with NHL. One way is to treat as many of these patients as possible according to current standards. In the field of geriatric oncology, one of the questions we are often confronted with is the limitation of treatment, especially in frail patients. This issue is closely associated with ethical considerations which are discussed in another paper.     

Der Einfluß eines Gerontopsychiatrischen Zentrums auf die Versorgungsqualität psychisch erkrankter älterer Menschen

The goal of this evaluation study is to analyze the effects of a new gerontopsychiatric institution, the gerontopsychiatric center (GC: a combination of a home-based outpatient service, a day-hospital and a consulting office for elderly with mental disorders) on the reorganization process of the treatment system from intramural toward extramural structures, as experts of the government of the FRG have been demanding for a long time. Based on data of cross-sectional and longitudinal studies two regional catchment areas--the city of Bielefeld (without GC, control region) and the district of Gütersloh (with GC)--are compared and analyzed, whether changes within the gerontopsychiatric system (subsystem A), the system of general medical treatment (subsystem B), or within the elderly care system (subsystem C) occurred. Concerning subsystem A the results are that the GC has a strong impact on the intended shift from intra- to extramural structures, without selecting patients by diagnosis nor by severity degrees of their mental disorders in extramural treatment facilities. The home-based outpatient treatment is especially successful for elderly with a functional psychic disorder. These patients had the highest scores in improvement of psychiatric symptoms as well as in reduction of their self-care deficits within one year. Effects of the GC on subsystem B were evident soon after its establishment, for example, by the increasing cooperation between the gerontopsychiatric health services and general hospitals in the region with GC, in which (hospitals) two fifths of all clinical gerontopsychiatric patients with a mental disorder as the main diagnosis (ICD-9) are treated. An effect of the GC on subsystem C is possibly the fact that in its region the rate of direct transfers of patients from the clinical gerontopsychiatric department into homes for the elderly is significantly lower than in the region without GC.     

Alter und Migration—

In the course of demographic change, the number of elderly migrants increases, and the population of elderly people in Germany becomes more varied-facts that have to be taken into account more intensely when it comes to planning services for elderly people in the future. The need for action is intensified by the fact that elderly migrants are still worse off than natives of the same age in many areas of life (e. g. income, health, etc.). At the same time, elderly migrants cannot automatically be regarded as helpless or isolated because of their solid family help networks.Meanwhile, on political and social levels, approaches have been developed to open services and institutions for the special needs of minority ethnic elders. Furthermore, offers have been established by the creation of ethnic-specific emphases that focus on the life style and the everyday life of the target group. In spite of all these efforts, the whole range of care services for the population of elderly migrants is still regarded as insufficient by experts. Therefore, especially in the fields of networking, cooperation and controlling of the people involved, information transfer, and training measures that aim at better preparing the provider of care services for elderly people are highly recommended in order to meet the increasing needs of help and care of older migrants more precisely.     

III. Soziale Beziehungen

In this four-part review article, an update of psychological gerontology from 1988 to 1997/1998 in German speaking countries is given. Part III of this review focuses on social relationships in old age. Two perspectives are chosen for this analysis. The first perspective describes the process of actively coping with developmental tasks in social relationship - the elderly are not seen as a "passive" but as an "active" part in social relationships. Moreover, this perspective focuses on empirical relations between different patterns of social integration and the psychological situation in old age. The second perspective stresses on a special aspect of social engagement: the engagement and productivity in intergenerational relationships. Empirical data make clear that the elderly not only receive (emotional and instrumental) support, but also give a lot of support in these relationships.     

Inanspruchnahme medizinischer Leistungen und Medikamenteneinnahme bei über 60jährigen in Deutschland –gesundheitliche, sozialstrukturelle, sozio-demographische und subjektive Faktoren

In a community sample of 394 elderly aged 61 years and older from East and West Germany, diseases, contacts with general practitioners and specialists, the use of medicine, attitudes regarding health and illness, the subjective health, psychic problems, social support, social integration, social burden, and socio-demographic variables were assessed. Based on these data the determinants for the contact of physicians and the use of medicine were analyzed. The results confirmed the frequency of multimorbidity in the elderly; on average we found three different diseases at the same time for each person. In nearly 10% of the sample we found seven diagnoses existing at the same time. 88% had contact with a general practitioner at least once a year, 97% had contact either with a general practitioner or with a specialist once a year. 55.8% took at least one medicine each day. The number of diseases existing at the same time was the most determining variable for the contact of physicians and the use of medicine. Furthermore, the elderly had more contact with physicians and took more medicine if they thought they were susceptible to diseases in a high degree, and if they rated their own health as poor. Fewer contacts with physicians and a lower use of medicine were found in those elderly that rated health behavior as little useful, that had low control beliefs regarding their own health, and that experienced only a low degree of health-related limitations in their everyday life. Furthermore, we found a higher use of medicine if there was little social support. There were no significant age-related or sex-related differences regarding the contact of practitioners or the use of medicine.     

Evidence Based Medicine und die Umsetzung neuer Therapien in die Praxis: Wunsch und Realität

In the last years some important therapies were introduced in the treatment of rheumatoid arthritis (RA), which represent a significant clinical advance. This concerns the introduction of TNF blockade with etanercept and inflixmab, the combination of DMARDs, leflunomide and the COX-2-specific inhibitors. In the year 2000 the restrictive social law in Germany, the collective and individual budgets for medicaments, did prevent a broader use of the very expensive therapy with TNF blockade. A rising number of international healthcare studies shows a profound potential for saving costs by improving the functional capacity (HAQ) in patients with RA. The biologicals and leflunomide have this potential. To realise the potential of reducing healthcare costs by an optimal therapy of RA some modification of the restrictive social law is necessary as well as the introduction of disease-management programs.     

Intensivmedizin bei älteren Patienten: Wie nützlich sind die Scoresysteme APACHE II und III?

OBJECTIVE: Scores like APACHE (Acute Physiology And Chronic Health Evaluation) were evaluated for unselected intensive care unit (ICU) admissions. Can they also be used for risk stratification and quality assurance in selected subgroups like elderly patients? METHODS: Over a 3-year period data of all admissions of a 12 bed interdisciplinary ICU were collected. APACHE II and III scores and probabilities of hospital deaths were compared with observed outcomes. The discriminatory power was evaluated by calculating the areas under the receiver operating characteristic (ROC) curves. Calibration was analyzed with standardized mortality ratios (SMR) and the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS: Of 3382 admissions due to exclusion criteria, 2795 patients were analyzed, 1396 (49.9%) of these were > or = 65 years, mean age 75 (65-99) years. 62.5% were non-operative, 37.5% postoperative admissions, 35% after emergency operations. ICU mortality was 11.7%, hospital mortality 25.1%. The areas under the ROC curves were 0.77 for APACHE II and 0.79 for APACHE III (whole collective 0.83 and 0.85, respectively). The SMR was 1.17 for APACHE II and 1.23 for APACHE III compared with 1.06 and 1.22 for all patients, respectively. Calibration for elderly patients was insufficient for APACHE II (Hosmer-Lemeshow chi-square = 19, p < 0.025) as well as for APACHE III (chi-square = 41, p < 0.001), while it was good for all patients for APACHE II (chi-square = 12, p > 0.1) but not so for APACHE III (chi-square = 48, p < 0.001). CONCLUSIONS: APACHE II and III both show good discrimination for elderly patients although a little inferior than for all patients. Both scores can be used for risk stratification of elderly ICU patients. Mortality prognosis is not sufficient for geriatric patients although APACHE II calibrates well for all. Application of these scores for quality assurance in selected subgroups like elderly patients cannot be recommended based on these data.     

Therapy of acute myeloid leukemia in the elderly patient

Incidence and mortality rates of acute myeloid leukemia (AML) increase exponentially with advancing age. AML diagnosed in elderly patients differs from that diagnosed in younger patients. But not only disease-specific differences are important. Treating elderly patients with AML age-associated differences in the patients general presentation, such as physiological changes in organ function, decreased ability to react to stress, dependence in activities of daily living, existence of other morbidities (co-morbidity), the need to take drugs for those diseases and the reduced life expectancy can force alterations in the disease management. Clinical trials for the treatment of AML have been excluding elderly patients for years. Even trials accepting elderly patients with AML did select the group of otherwise healthy elderly patients for participation in the trial. Thus the data for AML management in elderly patients do not reflect the whole group of elderly patients with AML. If the patient is treated with curative intention, therapy of choice is the so-called 3 + 7 protocol for induction of complete remission, followed by a consolidation therapy and in some cases by maintenance therapy. In some situations, especially in very old patients, a palliative intention to treatment is favored. There are no generally accepted criteria to measure treatment benefit in this setting nor established chemotherapy protocols for this situation. Further trials for elderly patients with AML have to offer treatment options for the whole group of patients and have to determine what treatment approach is the best for which individual patient.     

Intergenerational family relations and social support

Summary A parallel process to the aging of societies in the Western world occurs in changing family structures and network compositions. The shape of families is shifting from horizontal to vertical, where the size of generations is becoming smaller but the number of living generations is increasing. Recently there is an increased emphasis in the study of intergenerational relations on the independence of generations. The “aging of the aged”, though, means the need for more care and support. It is well documented that there is continued high involvement of families in care giving. However, as the age structure of the society and the family change so does the availability and ability for care of its networks. The presentation will, thus, discuss and analyze the following three issues: First, a theoretical perspective on family intergenerational relationships will be presented, based on social exchange theory and the intergenerational solidarity model. Empirical findings will focus on grandparent-grandchild relations and on immigrant families, stressing the importance of ethnicity. Second, care giving and support to frail elderly family members, in different types of living arrangements, will be described and analyzed, as a major topic in research and policy. Third, the relations and impact of family solidarity, support and care on the quality of life of the older people will be discussed. Received: 10 July 1999, Accepted: 3 August 1999     

Evidenz-basierte Medizin: eine Einführung für klinisch Tätige

In Germany, the term "evidence-based medicine" still leads to confusion. To our continental understanding "evidence" refers to the self-evident, what is obvious and unequivocally clear without any methodological mediation. In English speaking countries, "evidence" is defined as available and disputable facts indicating whether or not a proposition is valid. In clinical medicine both types of evidence are indispensable. However at present "external (i.e. anglosaxon) evidence" from sound-evaluative clinical research is actually needed to define and justify clinical indication rules. The rationale of the concept is obviously consequentialistic, it primarily considers the clinical and community effectiveness of any medical intervention. The paper finally discusses some of the ethical problems involved in evidence-based medicine.     

Präventive Hausbesuche im Alter: Entwicklung und Pilottestung eines multidimensionalen Abklärungsinstruments

Preventive home visits with multidimensional geriatric assessment have been shown to delay or prevent the onset of disability and reduce nursing home admissions in older people. The purpose of the present study was to develop and test a multidimensional instrument for in-home preventive assessments in older persons. In developing the instrument, we conducted a systematic literature review of risk factors for functional status decline and of appropriate instruments for measuring these risk factors. Based on an Expert Panel using a modified Delphi process [1] the risk factor domains for functional status decline were chosen, [2] the instruments for evaluating each of the included risk factor domains were selected, and [3] the individual instruments were combined into one comprehensive assessment instrument. A German language version of the original English version of the instrument was developed based on translation, backtranslation, and cultural adaptation. The feasibility of use of the new instrument was evaluated in a field test in 150 people aged 75 years and older in Hamburg, Ulm, Germany, and Bern, Switzerland. The instrument was well accepted by the older persons. The prevalence of risk factors for functional status decline in these populations (e.g., physical inactivity, urinary incontinence, vision impairment) was high. There was also a high prevalence of underuse of preventive care measures (e.g., no pneumococcal vaccination in over 95 percent of persons). These preliminary results support the possible usefulness of this instrument for conducting preventive home visits or for epidemiological purposes (e.g., prevention surveillance). In a next phase, the test-retest reliability of the instrument, and the feasibility and reliability of self-administration as compared to interviewer administration will be described in a separate paper.     

Ageing in Europe – challenges and consequences

Summary This article outlines the five key social and economic policy challenges presented by the ageing population of the European Union (EU). These challenges are the maintenance of economic security in old age, preserving intergenerational solidarity, combating the social exclusion created by age discrimination, providing long-term care in the context of changes in family and residence patterns, and enabling older people to participate in society as full citizens. The nature of each of these challenges is discussed and priorities pinpointed. The discussion of policy challenges is preceded by an outline of the demographic context of the EU: the combination of delining fertility and increasing longevity. This also includes a discussion of the links between demography and policy. The conclusion of the article considers the current threat to the European model of social policy and suggests ways in which the gerontological community might contribute to its defence. Received: 8 July 1999, Accepted: 26 July 1999     

Conceptual and ethical questions in geriatric oncology

Geriatric oncology concentrates on the field of cancer in the expanding aging population. Therapeutic goals are based on individual risk-assessment, comorbidities, and the specific tumor-biology. Good management of older cancer patients requires a multidimensional risk profile. Shared decision-making in geriatric oncology has to recognize a sometimes impaired autonomy. Possible conflicts between beneficence and autonomy are discussed and specific problems of the elderly patients are given. Informed consent requires competence, which might be lacking to some degree. It is the task of a responsible physician to promote autonomous decision-making as far as possible.     

Chemotherapy of non-small-cell bronchial carcinoma in elderly patients

The incidence of lung cancer increases with age, and non-small-cell histotypes account for approximately 85% of lung cancers in patients aged older than 65 years. Results of large multicentric trials provide no evidence that elderly lung cancer patients who receive systemic chemotherapy have a worse outcome than younger patients. There is, however, an underrepresentation of older patients in cancer treatment trials, at least in part due to the stringent eligibility criteria of these trials. Recent studies specifically designed for elderly patients with advanced non-small-cell lung cancer have shown that chemotherapy improves survival and disease-related symptoms also in this age group. However, the degree of comorbidity was found to affect both the tolerance to treatment and the survival outcome.     

"Memory-clinics" in German-speaking countries

This article gives an evaluation of the organization, diagnostics and offers of therapy from 41 memory-clinics conducted in German-speaking countries and shows that there is no uniform standard for the care of those suffering from dementia. As a result there are problems with quality assurance and financing. The survey shows that Switzerland has the most extensive as well as intensive care program which is also appropriately funded. It is therefore necessary to provide guidelines for defining a uniform quality standard while taking into account the reasons of the various institutes for implementing such departments. It is also essential that these guidelines do justice to the patients and their relatives.     

Die Kosten hüftgelenksnaher Frakturen in Deutschland: Eine prospektive Untersuchung

OBJECTIVE: To assess the direct and indirect costs of hip fracture in dependence of postoperative care setting. STUDY DESIGN: Prospective cohort study. METHODS: 227 consecutive patients in three hospitals (city, town, and small town) presenting with hip fracture. For 177 patients there was follow-up regarding post-operative care-setting. During follow-up the cost of the remaining patient at 1, 3, 6 month were recorded and afterwards adjusted to the distribution of the initial cohort. To obtain information on patient characteristics, assessment during hospital stay and follow up have been performed. RESULTS: There was a relevant difference in costs depending on the care setting after hip fracture. The nursing home - nursing home, community - community, and community - nursing home resulted in total costs at 6 month of 17,701 DM, 27,102 DM and 54, 503 DM, respectively (average: 24,508 DM). Nursing home costs contributed significantly to the differences between groups. Valid and predictive measures could not be established in first analysis of performed assessments. CONCLUSION: Due to the high incidence of hip fractures (100,000/y) indirect costs play a major role in the economic impact of this illness. The analysis of the effectiveness of interventions has to take into account these costs to achieve adequate conclusions.     

Dementia: epidemiology, intervention and concept of care

Summary Dementia is going to be one of the major challenges of the next century for our societies due to the enormous burden on the health care systems. Dementia is the major cause of death and the most important risk factor for disability and entry into a nursing home in elderly people. Moreover, because of the progress in the treatment of Alzheimer's disease, in particular with the cholinesterase inhibitors, demented people will be more often and detected earlier by general practitioners and families. Thus, dementia will become progressively more a public problem than a private one. This tendency could be increased by the unemployment problem among young adults which obliges their parents to support them, neglecting then their own parents' problems. A possible way to win this challenge is prevention. Intervention on several risk factors of dementia in the elderly is possible. The Syst-Eur trial demonstrated recently that treatment of systolic high blood pressure could decrease the risk of dementia by 50%. Other vascular risk factors, depression, aluminium in drinking water, and active life are other good candidates for preventive intervention. Finally, secondary prevention by treatment among people with mild cognitive impairment will be another interesting way of delaying the onset of the disease and decrease it's prevalence. Received: 9 July 1999, Accepted: 4 August 1999     

Das Immunsystem im Alter

The immune system changes during life time. In this article we review which kinds of alterations take place. To exclude changes based on illnesses or chronical diseases, the SENIEUR protocol was performed, which defines "healthy elderly people". We focus on alterations in lymphocyte subsets, immunoglobulins and the cytokine network. Monocytes, eosinophils and basophils are without change during life, whereas the number of neutrophils and natural killer (NK) cells increase with aging. T- and B-lymphocytes are diminished in number as well as in function. The serum levels of immunoglobulins are mostly increased. The balance between TH1- and TH2-cells is disturbed and also TH1- and TH2-specific cytokines. Theses changes and their effects on the health status of the elderly are discussed in detail.     

Geriatrische Versorgung, ökonomischer Nutzen und die Euthanasiedebatte

Three characteristic developments in modern western societies usually are considered to be independent variables in the ethical discussion:1. An explosion-like increase in medical and social expenditures following a rapid multiplication of old and multiply disabled people in this century. 2. the increasing economic importance of the "health industry", and 3. the "new" debate of euthanasia. All these developments are discussed controversially. The volume of geriatric support is mostly considered to be insufficient, but usually it is restricted by both, scarcity of resources as well as increasing demands to focus on "evidence-based medicine" (which might exclude a lot of medical procedures in old age). The mutation of health systems from - originally - social activities to business branches more and more gives priority to economical based decisions in medicine, but otherwise has advanced an increasing number of new health professions.The origin of the actual debate on euthanasia is the development and judicial certification of individual's self-determination in modern societies. However, euthanasia is still refused world-wide because it is considered to be linked with a process of weakening basic ethical principles. The 3 seemingly independent developments certainly are facts in modern societies. They hardly can be influenced by the medical profession, being forced to conform to them. However, there are significant connections between them.A geriatric health system, primarily denying individual demands and basic convictions of old people, contributes to an attitude of non-acceptance towards daily practice medicine. The same effect may result from the economic transformation of medicine when creating a system of self-perpetuating demand (being characteristic for an "ideal" business branch) by "unlimited" prolongation of life of the very old and highly disabled patients.The result from this development undoubtedly will be an increasing demand for self-determination at the end of life, including medical assistance in suicide and euthanasia, which cannot successfully be confronted with moral appeals.Alternatively, a basic correction of the geriatric health system must be introduced mainly including psychodynamic factors in medical decision making, or euthanasia will be accepted by the majority, as already has happened in the Netherlands.