Rating chronic medical illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale

Medical burden in late-life bipolar and major depressive disorders

BACKGROUND

Elderly patients with bipolar disorder have been found to have higher mortality than those with major depressive disorder. The authors compare medical burden in elderly patients with bipolar disorder with that in those with major depressive disorder.

METHODS

Fifty-four patients with bipolar I or II disorder who were 60 years of age and older were equated 1-to-2 to 108 patients with nonpsychotic, major depressive disorder according to age, sex, race, and lifetime duration of mood disorder illness. Variables examined included the following: Cumulative Illness Rating Scale for Geriatrics (CIRS-G) total scores, body mass index (BMI), and CIRS-G subscale scores.

RESULTS

Compared with patients with major depressive disorder, patients with bipolar disorder had similar levels of general medical comorbidity on the CIRS-G total score and number of systems affected but higher BMI. After controlling for multiple comparisons, the endocrine/metabolic and respiratory subscale scores on the CIRS-G were higher for patients with bipolar disorder.

CONCLUSION

Although overall medical burden appears comparable in elderly patients with bipolar and those with major depressive disorder, patients with bipolar disorder have higher BMI and greater burden of endocrine/metabolic and respiratory disease.

Management of Frail and Not-Frail elderly cancer patients in a hospital-based geriatric oncology program

PURPOSE

To evaluate management and outcome of patients >or=70 years admitted to our Medical Oncology ward and evaluated by Multidimensional Geriatric Assessment before treatment with standard or "elderly-friendly" chemotherapy regimens, a list of which was developed within our Geriatric Oncology Program based on published clinical trials and personal experience.

PATIENTS AND METHODS

Charts of patients treated from January 2004 to January 2006 were reviewed for choice of treatment, tumor response, toxicities and survival.

RESULTS

117 patients (median age 75 years) were divided into Frail (F) (34.2%) and Not-Frail patients (NF: 33.3% Fit plus 32.5% Vulnerable). The two groups did not differ according to the use of "elderly-friendly"chemotherapy regimens (40% of F pts and 39% of NF pts), dose reductions >or=25% (37.5% vs. 31.2%) and grade 3-4 toxicities (52.5% vs. 58.4%). Early interruption of treatment due to toxicity or patient's refusal (42.5 vs. 15.6, p=0.001) and deaths within 30 days from last chemotherapy administration (22.5% vs. 3.9%, p=0.003) were significantly different. F patients showed clinical or radiological response in 21.2% of cases, and subjective improvement in 22.6%. After a median follow-up of 19 months, median survival of F patients (6.4 months) is shorter compared to NF group (16.9 months, p=0.012).

CONCLUSIONS

The use of "elderly-friendly"chemotherapy regimens was limited to less than a half of cases. F patients may respond to chemotherapy but display higher rates of premature withdrawal and early deaths compared to NF patients, with a shorter survival. Clinical trials particularly aimed at frail patients are urgently needed.

Comorbidities in rheumatoid arthritis

Rheumatoid arthritis (RA) is often characterized by the burden of swollen joints, pain, and decreased physical function, but less understood are the many manifestations of additional health conditions that are associated with RA and its treatments. First brought to light with observations of increased mortality in RA, studies noted the increased rates of cardiovascular and infection events. The chronic, debilitating, autoimmune nature of RA affects the patient directly or indirectly in almost all organ systems, from cardiovascular problems and infections to depression and gastrointestinal ulcers. On average, the established RA patient has two or more comorbid conditions. It should be the responsibility of the rheumatologist to take these and the risk of additional conditions into account when treating the patient. This chapter reviews important comorbidities in patients with RA, their prevalence, and their relation to RA.

Cognitive performance in suicidal depressed elderly: preliminary report

OBJECTIVE

Deficits in executive functions may play an important role in late-life suicide; however the association is understudied. This study examined cognitive function in general and executive functioning specifically in depressed elderly with and without suicidal ideation and attempts.

DESIGN

Case-control study.

SETTING

University-affiliated psychiatric hospital.

PARTICIPANTS

We compared 32 suicidal depressed participants aged 60 and older with 32 non-suicidal depressed participants equated for age, education, and gender.

MEASUREMENTS

We assessed global cognitive function and executive function with the Dementia Rating Scale (DRS) and the Executive Interview (EXIT25), respectively.

RESULTS

Suicidal and non-suicidal depressed groups were comparable in terms of severity of depression and burden of physical illness. Suicidal participants performed worse on the EXIT25, and on the DRS total scale, as well as on Memory and Attention subscales. The differences were not explained by the presence of dementia, substance use, medication exposure, or brain injury from suicide attempts.

CONCLUSIONS

Poor performance on tests of executive function, attention, and memory is associated with suicidal behavior in late-life depression.

Community occupational therapy for older patients with dementia and their care givers: cost effectiveness study

OBJECTIVE

To assess the cost effectiveness of community based occupational therapy compared with usual care in older patients with dementia and their care givers from a societal viewpoint.

DESIGN

Cost effectiveness study alongside a single blind randomised controlled trial.

SETTING

Memory clinic, day clinic of a geriatrics department, and participants' homes. Patients 135 patients aged > or =65 with mild to moderate dementia living in the community and their primary care givers.

INTERVENTION

10 sessions of occupational therapy over five weeks, including cognitive and behavioural interventions, to train patients in the use of aids to compensate for cognitive decline and care givers in coping behaviours and supervision.

MAIN OUTCOME MEASURES

Incremental cost effectiveness ratio expressed as the difference in mean total care costs per successful treatment (that is, a combined patient and care giver outcome measure of clinically relevant improvement on process, performance, and competence scales) at three months after randomisation. Bootstrap methods used to determine confidence intervals for these measures.

RESULTS

The intervention cost 1183 euros (848 pounds sterling, $1738) (95% confidence interval 1128 euros (808 pounds sterling, $1657) to 1239 euros (888 pounds sterling, $1820)) per patient and primary care giver unit at three months. Visits to general practitioners and hospital doctors cost the same in both groups but total mean costs were 1748 euros (1279 pounds sterling, $2621) lower in the intervention group, with the main cost savings in informal care. There was a significant difference in proportions of successful treatments of 36% at three months. The number needed to treat for successful treatment at three months was 2.8 (2.7 to 2.9).

CONCLUSIONS

Community occupational therapy intervention for patients with dementia and their care givers is successful and cost effective, especially in terms of informal care giving.

Sleeping well, aging well: a descriptive and cross-sectional study of sleep in "successful agers" 75 and older

OBJECTIVES

To examine diary-based, laboratory-based, and actigraphic measures of sleep in a group of healthy older women and men (> or =75 years of age) without sleep/wake complaints and to describe sleep characteristics which may be correlates of health-related quality of life in old age.

DESIGN

Cross-sectional, descriptive study.

SETTING

University-based sleep and chronobiology program.

INTERVENTION

None.

PARTICIPANTS

Sixty-four older adults (30 women, 34 men; mean age 79).

MEASUREMENTS

We used diary-, actigraphic-, and laboratory-based measures of sleep, health-related quality of life, mental health, social support, and coping strategies. We used two-group t-tests to compare baseline demographic and clinical measures between men and women, followed by ANOVA on selected EEG measures to examine first-night effects as evidence of physiological adaptability. Finally, we examined correlations between measure of sleep and health-related quality of life.

RESULTS

We observed that healthy men and women aged 75 and older can experience satisfactory nocturnal sleep quality and daytime alertness, especially as reflected in self-report and diary-based measures. Polysomnography (psg) suggested the presence of a first-night effect, especially in men, consistent with continued normal adaptability in this cohort of healthy older adults. Continuity and depth of sleep in older women were superior to that of men. Diary-based measures of sleep quality (but not psg measures) correlated positively (small to moderate effect sizes) with physical and mental health-related quality of life.

CONCLUSIONS

Sleep quality and daytime alertness in late life may be more important aspects of successful aging than previously appreciated. Good sleep may be a marker of good functioning across a variety of domains in old age. Our observations suggest the need to study interventions which protect sleep quality in older adults to determine if doing so fosters continued successful aging.

An attempt to correlate a "Multidimensional Geriatric Assessment" (MGA), treatment assignment and clinical outcome in elderly cancer patients: results of a phase II open study

OBJECTIVES

To establish a correlation between a specific MGA category, an appropriate preventively established treatment and clinical outcome in a population of elderly cancer patients. The ultimate goal was to verify whether the appropriate treatment given to elderly cancer patients according to their MGA category could translate into a better clinical outcome assessed as clinical response and toxicity, i.e whether this process might achieve a clinically meaningful impact.

PATIENTS AND METHODS

We carried out a phase II open, prospective non-randomized study in 75 elderly cancer patients (lung, head and neck, colorectal, gynecologic and breast) hospitalized at the Department of Medical Oncology, University of Cagliari, Italy. All patients underwent MGA evaluation and were assigned to three different categories: fit, intermediate and frail. Thereafter, an appropriate preventively established treatment was administered and the clinical outcome was assessed. The clinical outcome after 3 month treatment was defined on the basis of objective clinical response and toxicity. The difference of clinical outcome in the MGA categories was assessed by ANOVA test. Moreover, the correlation between MGA category and the clinical outcome (clinical response and toxicity) was assessed by Spearman's correlation test.

RESULTS

A better clinical response was observed in fit patients as compared both to intermediate and frail patients. Treatment toxicity was comparable in the different MGA categories. The correlation analysis between MGA category, clinical response to treatment and toxicity showed that there was a significant direct correlation with clinical response and no correlation with toxicity. Overall, the regression analysis showed that MGA was predictive of clinical outcome, in the sense that it is truly predictive for clinical response and no predictive for toxicity.

CONCLUSION

Our study demonstrates that the MGA, although time-consuming, is a useful and cost-benefit effective tool to appropriately select elderly cancer patients to be treated effectively in terms of a survival advantage and those who would benefit mainly in terms of improvement of quality of life. Moreover, the treatment preventively established for each MGA category was shown to be adequate and accomplished the most appropriate performances in terms of effectiveness and toxicity.

The impact of an aging population on the diagnosis of pulmonary embolism: comparison of young and elderly patients

The influence of age on predisposing factors, diagnostic tests, and clinical presentation of pulmonary embolism was evaluated in 582 subjects with suspected pulmonary embolism (180 aged <65 years; 402 aged > or =65 years) consecutively enrolled at the Emergency Department. Pulmonary embolism was confirmed in 40% of patients, 75% of those were aged >65 years. Age was directly related to the diagnosis, and the observed probability was higher than the expected probability in the 70 to 79 year subgroup. Score at the Cumulative Illness Rating Scale significantly increased as a function of both age and pulmonary embolism. Dyspnea, syncope, jugular distension, and history of previous venous thromboembolism were more frequently observed in elderly patients. In-hospital mortality rate among the elderly and younger patients was 2% and 0.2%, respectively. The authors conclude that age > or =65 years and high comorbidity are risk factors for pulmonary embolism.

Ethnicity/race and outcome in the treatment of depression: results from STAR*D

OBJECTIVES

This secondary analysis of data from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study compared rates of remission and response for blacks (n = 495), whites (n = 1853), and Hispanics (n = 327) with nonpsychotic major depressive disorder who were treated with citalopram.

METHODS

STAR*D included representative outpatients treated in 23 psychiatric and 18 primary care centers. Participants received flexible doses of citalopram for up to 14 weeks, with dosage adjustments based on routine clinical assessments. Efforts were made to achieve remission, using a measurement-based care approach with adjustments based on symptoms and side effects assessed at each visit.

RESULTS

There were significant differences among groups on many baseline demographic, sociocultural, and clinical variables. Blacks and Hispanics were more socially disadvantaged and had more comorbidity than whites. Before adjusting for differences, blacks had lower remission rates than whites, with Hispanics intermediate between the 2. After adjustments, remission rates for groups were not significantly different on the 17-item Hamilton Rating Scale for Depression (HRSD), but remained lower for blacks compared with whites with the 16-item Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR). Blacks took longer to achieve remission or response, though this did not remain after adjusting for baseline differences.

CONCLUSIONS

Overall, black and to a lesser extent Hispanic participants had a poorer response to citalopram. After adjusting for baseline differences, the remission rates seemed to be more similar on the HRSD, but remained worse for blacks on the QIDS-SR. We discuss the possible biologic and sociocultural factors that may underlie these findings.

Association between antihypertensive medication use and non-cardiovascular outcomes in older men

BACKGROUND

Antihypertensive drugs are prescribed commonly in older adults for their beneficial cardiovascular and cerebrovascular effects, but few studies have assessed antihypertensive drugs' adverse effects on non-cardiovascular outcomes in routine clinical practice.

OBJECTIVE

To evaluate, among older adults, the association between antihypertensive medication use and physical performance, cognition, and mood.

DESIGN AND SETTING

Prospective cohort study in a Veterans Affairs primary care clinic, with patients enrolled in 2000-2001 and assessed for medication use, comorbidities, health behaviors, and other characteristics; and followed-up 1 year later.

PARTICIPANTS

544 community-dwelling hypertensive men over age 65 years.

MEASUREMENTS

Timed chair stands; Trail Making Test part B; and Centers for Epidemiologic Studies Depression (CES-D) scores.

RESULTS

Participants had a mean age of 74.4 +/- 5.2 years and took a mean of 2.3 +/- 1.2 antihypertensive medications at baseline. After adjustment for age, comorbidities, level of blood pressure, and other confounders, each 1-unit increase in antihypertensive medication "intensity" was associated with a 0.11-second (95% confidence interval, 0.05-0.16) increase in the time required to complete the timed chair stands. No significant relationship was found between antihypertensive medication intensity and outcomes for Trail Making B or CES-D scores.

CONCLUSIONS

A higher cumulative exposure to antihypertensive medications in community-living older men was associated with adverse effects on physical performance, but not on the cognitive or depression measures available in this study. Clinicians should consider non-cardiovascular related adverse effects when treating older males taking multiple antihypertensive medications.

Subsyndromal depressive symptoms in middle-aged and older persons with schizophrenia

OBJECTIVE

The objectives are to delineate the nature of subsyndromal depressive symptoms (SSD) in midlife and older patients with schizophrenia and schizoaffective disorder by: 1) describing the relationship of SSD with a number of other clinical features; and 2) examining which specific depressive symptoms are increased in patients broadly defined as having SSD.

METHODS

A total of 204 participants with schizophrenia or schizoaffective disorder and SSD who entered a federally funded intervention study at the University of California San Diego (UCSD) and University of Cincinnati were matched with schizophrenic and schizoaffective participants from the Geriatric Research Center at UCSD who had minimal or no depressive symptoms. The SSD and no depression groups were compared on a variety of clinical features including general psychopathology, positive and negative symptoms, medical and mental functioning, cognition, movement abnormalities, and specific depressive symptomatology.

RESULTS

SSD was associated with increases in overall psychopathology; positive and negative symptoms; severity of general medical conditions; impaired physical and mental functioning; possibly more severe akathisia; and more depressive symptoms throughout the spectrum of symptom clusters measured by the Hamilton Depression Rating Scale, including anxiety and suicidality.

CONCLUSIONS

SSD in middle aged and older patients with schizophrenia is an important clinical dimension that appears to be associated with substantial morbidity and distress. The findings suggest that is important for clinicians to look for and assess subsyndromal depressive symptoms in patients with chronic schizophrenia.

Determining therapeutic approaches in the elderly with rectal cancer

BACKGROUND

To evaluate the toxicity and feasibility of pelvic radiotherapy (RT) and/or surgery in elderly patients with locally advanced low-lying rectal cancer.

PATIENTS AND METHODS

From November 1999 to November 2005, 51 patients aged >or=70 years who underwent RT for locally advanced low-lying rectal cancer were retrospectively examined. Variables considered were age, co-morbidities (evaluated according to the Charlson score and the Cumulative Illness Rating Scale-Geriatric [CIRS-G] score) and surgery versus no surgery.

RESULTS

The median age was 80 years (range 70-94 years) and the male : female ratio was 33 : 18. A total of 5.9% of patients were considered 'fit', 72.5% had one or more CIRS-G grade 1 or 2 co-morbidities and 21.6% had one or more CIRS-G grade 3 co-morbidities. 54.9% of patients underwent surgery and 45.1% underwent RT. Only 9 of 21 (42.8%) patients who underwent radical resection received the full course of adjuvant RT and only seven (50%) of all patients treated with RT alone received the full dose of therapy. Patients with one or more CIRS-G grade 3 co-morbidities reported similar numbers of grade 1-2 toxicities as patients with one or more CIRS-G grade 2 co-morbidities.

CONCLUSION

Notwithstanding the small number of patients analysed, the findings of this study indicate that elderly patients with rectal cancer and mild co-morbidities could probably receive the same treatment as fit elderly patients, given that tolerability appeared to be similar in both categories of patients. Neither age nor co-morbidities should be considered reasons to deny the patient the possible benefits of receiving complete treatment. Moreover, Multidimensional Geriatric Assessment should always be undertaken to help clinicians make better decisions about treatment. Further prospective trials are needed to confirm these results.

Quality of life concerns and end-of-life care preferences of aged persons in long-term care facilities

AIMS AND OBJECTIVES

This study aimed at understanding quality of life (QOL) concerns and end-of-life care preferences of older people living in long-term care facilities in Hong Kong.

BACKGROUND

Previous studies about the QOL of residents in long-term care facilities were often from a qualitative perspective, because it could yield an in-depth description of the experience. Quantitative studies in this area were not only scarce, but also less specific in capturing the concerns of this vulnerable group. Their forethought about their care planning was also overlooked.

DESIGN AND METHOD

We successfully interviewed 287 older residents from 10 long-term care homes using the modified Quality-of-Life Concerns in the End of Life Questionnaire (QOLC-E) in a cross-sectional survey.

RESULTS

The mean (SD) ages of the frail and non-frail groups were 83.8 (6.74) and 82.35 (5.82) respectively. The majority of them were female and widowed. Existential distress, value of life and food-related concerns were the least desirable QOL concerns in both groups. Considerable numbers were uncertain about their end-of-life care preferences and they preferred their physician to be their surrogate.

CONCLUSION

The older residents had similar QOL concerns as patients with terminal or advanced diseases. Most of the older residents welcomed discussion about death and dying but had not planned for their end-of-life care and had a high regard for their physicians' authority.

RELEVANCE TO CLINICAL PRACTICE

The results reveal the major QOL concerns among the older residents living in long-term care facilities. This study, which is an initial step in profiling the older people's end-of-life care preferences, also shed light on how to formulate advance care planning in long-term care facilities.

The effect of co-morbidity on the rehabilitation process in elderly patients after hip fracture

We conducted a prospective observational study involving patients older than 65 years admitted for rehabilitation to the Geriatric Department of a university hospital after surgical treatment of hip fracture. We assessed functional status before, during and at the end of rehabilitation and as a measure of success of rehabilitation we calculated the Montebello Rating Factor Score (MRFS). In an attempt to make this index more reflective of changes in rehabilitative status we revised it accordingly. We measured demographic characteristics, cognitive function, affective status and co-morbidity. Data were collected from 102 patients with average age 79.0+/-6.5 years over a period of 12 months. In the uinvariant analysis, cognitive status, length of stay in Geriatric Department and co-morbidity were found as significant predictors of rehabilitation success. In the linear regression only Severity Index (SI) of Cumulative Illness Rating Scale for Geriatrics (CIRS-G) was found as a statistically significant predictor of rehabilitation outcome. In our context, we found that only co-morbidity (as measured by CIRS) is the best predictor of rehabilitation outcome of elderly patients after surgical repair of hip fracture.

Effects of community occupational therapy on quality of life, mood, and health status in dementia patients and their caregivers: a randomized controlled trial

BACKGROUND

Cure of dementia is not possible, but quality of life of patients and caregivers can be improved. Our aim is to investigate effects of community occupational therapy on dementia patients' and caregivers' quality of life, mood, and health status and caregivers' sense of control over life.

METHODS

Community-dwelling patients aged 65 years or older, with mild-to-moderate dementia, and their informal caregivers (n = 135 couples of patients with their caregivers) were randomly assigned to 10 sessions of occupational therapy over 5 weeks or no intervention. Cognitive and behavioral interventions were used to train patients in the use of aids to compensate for cognitive decline and caregivers in coping behaviors and supervision. Outcomes, measured at baseline, 6 weeks, and 12 weeks, were patients' and caregivers' quality of life (Dementia Quality of Life Instrument, Dqol), patients' mood (Cornell Scale for Depression, CSD), caregivers' mood (Center for Epidemiologic Studies Depression Scale, CES-D), patients' and caregivers' health status (General Health Questionnaire, GHQ-12), and caregivers' sense of control over life (Mastery Scale).

RESULTS

Improvement on patients' Dqol overall (0.8; 95% confidence interval [CI], 0.6-.1, effect size 1.3) and caregivers' Dqol overall (0.7; 95% CI, 0.5-.9, effect size 1.2) was significantly better in the intervention group as compared to controls. Scores on other outcome measures also improved significantly. This improvement was still significant at 12 weeks.

CONCLUSION

Community occupational therapy should be advocated both for dementia patients and their caregivers, because it improves their mood, quality of life, and health status and caregivers' sense of control over life. Effects were still present at follow-up.

A double-blind comparison of citalopram and risperidone for the treatment of behavioral and psychotic symptoms associated with dementia

OBJECTIVE

To compare citalopram and risperidone for the treatment of psychotic symptoms and agitation associated with dementia, with a priori hypotheses that risperidone would be more efficacious for psychosis and citalopram for agitation.

METHODS

A 12-week randomized, controlled trial in nondepressed patients with dementia hospitalized because of behavioral symptoms (N = 103) was conducted at the University of Pittsburgh Medical Center. Participants were consecutively recruited on an inpatient unit if they had at least one moderate to severe target symptom (aggression, agitation, hostility, suspiciousness, hallucinations, or delusions). Once they improved sufficiently, they were discharged to nursing homes, personal care homes, or residential homes for continued treatment. Planned pre-post and mixed model analyses of the main outcome measures of Neurobehavioral Rating Scale and Side Effect Rating Scale at baseline and at weekly/biweekly intervals were conducted.

RESULTS

Completion rates did not differ for citalopram and risperidone (overall completion rate: 44%). Agitation symptoms (aggression, agitation, or hostility) and psychotic symptoms (suspiciousness, hallucinations, or delusions) decreased in both treatment groups but the improvement did not differ significantly between the two groups. There was a significant increase in side effect burden with risperidone but not with citalopram such that the two groups differed significantly.

CONCLUSION

No statistical difference was found in the efficacy of citalopram and risperidone for the treatment of either agitation or psychotic symptoms in patients with dementia. These findings need to be replicated before citalopram or other serotonergic antidepressants can be recommended as alternatives to antipsychotics for the treatment of agitation or psychotic symptoms associated with dementia.

Predicting 6-week treatment response to escitalopram pharmacotherapy in late-life major depressive disorder

OBJECTIVE

Approximately half of older patients treated for major depressive disorder (MDD) do not achieve symptomatic remission and functional recovery with first-line pharmacotherapy. This study aims to characterize sociodemographic, clinical, and neuropsychologic correlates of full, partial, and non-response to escitalopram monotherapy of unipolar MDD in later life.

METHODS

One hundred and seventy-five patients aged 60 and older were assessed at baseline on demographic variables, depression severity, hopelessness, anxiety, cognitive functioning, co-existing medical illness burden, social support, and quality of life (disability). Subjects received 10 mg/d of open-label escitalopram and were divided into full (n = 55; 31%), partial (n = 75; 42.9%), and non-responder (n = 45; 25.7%) groups based on Hamilton depression scores at week 6. Univariate followed by multivariate analyses tested for differences between the three groups.

RESULTS

Non-responders to treatment were found to be more severely depressed and anxious at baseline than both full and partial responders, more disabled, and with lower self-esteem than full responders. In general partial responders resembled full responders more than they resembled non-responders. In multivariate models, more severe anxiety symptoms (both psychological and somatic) and lower self-esteem predicted worse response status at 6 weeks.

CONCLUSION

Among treatment-seeking elderly persons with MDD, higher anxiety symptoms and lower self-esteem predict poorer response after six weeks of escitalopram treatment.

Prevalence of diabetes mellitus in elderly patients received enteral nutrition long-term care service

The purpose of this study was to determinate the prevalence of undiagnosed diabetes mellitus (UDM) using glycated hemoglobin (GHb) among functionally dependent and severe cognitive depressed elderly long-term care (LTC) patients received enteral nutrition. The patients were divided into three categories: control, patients with (diabetes mellitus, DM) and without previously diagnoses (UDM) of DM. Demographic, functional and cognitive status, laboratory data and rate of death were recorded. Patients with HbA-1c level of 7% and more were diagnosed as diabetic. On the baseline, 26% of the patients presented with known DM. Patients from control and previously UDM groups presented with similar fasting plasma glucose (FPG) and post-prandial glucose (PPG) levels, but were different by HbA-1c levels (p<0.001). In 79% of patients suffering from UDM, HbA-1c levels was more than 7%, and in 24% of them more than 8%. Prevalence of UDM was 21%. Patients from UDM were presented as borderline group between Control group (C-G) and DM. Those differences presented by all general characteristics of the patients: age, functional and cognitive status, BMI, comorbidity, laboratory data and rate of death. This study suggests that 47% of LTC patients who received enteral nutrition suffered from DM, and 44% of them were undiagnosed. The authors recommend that the GHb is a simple and an effective laboratory analysis in detection of DM in this group of patients.

The metric properties of a novel non-motor symptoms scale for Parkinson's disease: Results from an international pilot study

Non-motor symptoms (NMS) in Parkinson's disease (PD) are common, significantly reduce quality of life and at present there is no validated clinical tool to assess the progress or potential response to treatment of NMS. A new 30-item scale for the assessment of NMS in PD (NMSS) was developed. NMSS contains nine dimensions: cardiovascular, sleep/fatigue, mood/cognition, perceptual problems, attention/memory, gastrointestinal, urinary, sexual function, and miscellany. The metric attributes of this instrument were analyzed. Data from 242 patients mean age 67.2 +/- 11 years, duration of disease 6.4 +/- 6 years, and 57.3% male across all stages of PD were collected from the centers in Europe, USA, and Japan. The mean NMSS score was 56.5 +/- 40.7, (range: 0-243) and only one declared no NMS. The scale provided 99.2% complete data for the analysis with the total score being free of floor and ceiling effect. Satisfactory scaling assumptions (multitrait scaling success rate >95% for all domains except miscellany) and internal consistency were reported for most of the domains (mean alpha, 0.61). Factor analysis supported the a prori nine domain structure (63% of the variance) while a small test-retest study showed satisfactory reproducibility (ICC > 0.80) for all domains except cardiovascular (ICC = 0.45). In terms of validity, the scale showed modest association with indicators of motor symptom severity and disease progression but a high correlation with other measures of NMS (NMSQuest) and health-related quality of life measure (PDQ-8) (both, rS = 0.70). In conclusion, NMSS can be used to assess the frequency and severity of NMS in PD patients across all stages in conjunction with the recently validated non-motor questionnaire.

Major depressive disorder and comorbid cardiac disease: is there a depressive subtype with greater cardiovascular morbidity? Results from the STAR*D study

The authors conducted exploratory analyses to determine whether specific symptoms of major depressive disorder (MDD) are associated with cardiac disease in 4,041 outpatients at baseline in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. MDD was diagnosed with the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; depressive symptoms were evaluated with the 30-item Inventory of Depressive Symptomatology, Clinician-Rated; and cardiac disease, with the Cumulative Illness Rating Scale. After adjustments for gender, age, ethnicity, education, and employment status, sympathetic arousal and early-morning insomnia were significantly associated with cardiac disease. Prospective studies are warranted to confirm these results.

Extraction of information on elder motor ability from clinical and biomechanical data through data mining

This study aimed at evaluating the additional knowledge provided by a biomechanical test coupled with clinical tests for motor ability assessment. A database including clinical test scores and sit-to-stand test variables obtained from 110 medically stable elderly subjects was submitted to data mining by searching for association rules. The presence of rules revealed some redundancies due to sample homogeneity, as mainly observed in the joint analysis of a questionnaire for daily activities assessment (Nottingham test) and the sit-to-stand, and due to similar evaluated information, as resulted from the joint analysis of a balance and gait scale (Tinetti test) and the sit-to-stand. Conversely, when no association rules were found, the tests carried unrelated information. The associations mined while analysing these clinical tests encouraged the integration of biomechanical tests, increasing significantly its clinical applicability and reducing the information redundancy. The information extracted also allowed to highlight rules typical of elderly persons that may serve as a knowledge-based tool for the detection of possible deviation from normality.

Physician don't heal thyself: a descriptive study of impaired older doctors

BACKGROUND

The growing and welcome interest in the issues leading to distress and impairment in younger doctors has not been mirrored by a focus on the similar issues in older doctors which is surprising given the aging medical workforce.

OBJECTIVES

To improve understanding of impairment in older doctors and to facilitate the planning of primary prevention strategies.

METHOD

Consecutive case records of notifications to the Impaired Registrants Program of the New South Wales Medical Board, Australia, of doctors over 60 years from January 2000 to January 2006 (N = 41) were examined. Details of demographics, type of practice, nature of referral, medical morbidity, cognitive examination, psychiatric diagnosis and outcome of assessment were recorded.

RESULTS

Impaired older doctors suffered cognitive impairment (54%), substance abuse (29%) and depression (22%) and 17% had two comorbid psychiatric conditions. Twelve percent had frank dementia. Two work patterns--the "workhorse" and the "dabbler"--were observed, as was a culture of postponed retirement due to a sense of obligation and working "until you drop." Impaired older doctors were found to have higher chronic illness burden compared with community norms. Almost half were the subject of patient complaints or of poor performance within ten years of presentation.

CONCLUSION

To our knowledge there has been no other comprehensive examination of patterns of impairment in older doctors. Older doctors are prone to suffer "the four Ds": dementia, drugs, drink and depression. We need to encourage mature doctors to adapt to age-related changes and illness and validate their right to timely and appropriate retirement.

Do elderly cancer patients achieve an adequate dose intensity in common clinical practice?

BACKGROUND

Elderly patients rarely receive adequate dose intensity (DI) using conventional regimens. Possible causes are improper patient assessment, the chemotherapy (CT) regimen chosen, the number and severity of comorbidities, patient compliance and physician experience. To explore this issue, DI was retrospectively analyzed in elderly patients treated with conventional CT regimens for advanced solid cancer.

PATIENTS AND METHODS

Patients > or =69 years were evaluated. All patients had metastatic solid tumors. Comorbidities, performance status (PS), toxicities, number of CT cycles, dose reduction and discontinuation of treatment were recorded. Relative DI (RDI) was calculated and regressed against these parameters.

RESULTS

108 patients were eligible. The most frequent diagnoses were: lung, head-and-neck and colorectal cancer. In 48 patients (44%), their initially scheduled treatment was modified. Mean RDI was 79% (range 19-100%, SD 20.6). Grade 3/4 non-hematological and hematological toxicity occurred in 27 (35/130) and 8% of patients (11/130), respectively. In regression analysis, RDI was significantly associated with hematological toxicity. RDI affected response rate but not overall survival.

CONCLUSIONS

RDI is significantly affected by toxicity. These data suggest the importance of the treatment schedule and patient selection as predictorsof adequate treatment. Some non-ratable variables, however, might also play a role regarding the dose intensity delivered.

Anxiety and depression: main determinants of health-related quality of life in Brazilian patients with Parkinson's disease

Determinants of health-related quality of life (HRQoL) were assessed in 115 Brazilian patients (56.5% males; mean age 62.5 years) with Parkinson's disease (PD). Hoehn and Yahr (H&Y) staging, Scales for Outcomes in Parkinson's Disease-Motor Scale (SCOPA-MS), Cumulative Illness Rating Scale-Geriatrics, Hospital Anxiety and Depression Scale (HADS), Parkinson's Disease Questionnaire (PDQ-39), and SCOPA-Psychosocial Questionnaire (SCOPA-PS) were applied. Median H&Y was 3 and the SCOPA-MS score was 25.6+/-13.1. The proportion of patients who scored > or =11 points in the HADS-Depression and HADS-Anxiety subscales were 47% and 30.4%, respectively. In the multivariate model, HADS-Anxiety or HADS-Depression (p<0.0001), disability (SCOPA-MS II) (p=0.0001) and comorbidity (p=0.0005) were independently associated to PDQ-39 and SCOPA-PS. Mood disturbances were the main determinants of HRQoL.

Multimorbidity and quality of life: a closer look

BACKGROUND

The presence of multiple chronic conditions is associated with lower health related quality of life (HRQOL). Disease severity also influences HRQOL. To analyse the effects of all possible combinations of single diseases along with their severity on HRQOL seems cumbersome. Grouping diseases and their severity in specific organ domains may facilitate the study of the complex relationship between multiple chronic conditions and HRQOL. The goal of this study was to analyse impaired organ domains that affect the most HRQOL of patients with multiple chronic conditions in primary care and their possible interactions.

METHODS

We analysed data from 238 patients recruited from the clientele of 21 family physicians. We classified all chronic conditions along with the measure of their severity into the 14 organ domains of the Cumulative Illness Rating Scale (CIRS). Patients also completed the 36-item Medical Outcomes Study questionnaire (SF-36). One-way analyses of variance were performed to study the relationship between the severity score for each CIRS domain and both physical component summary (PCS) and mental component summary (MCS) of HRQOL. Two-way analyses of variance were conducted to investigate the significance of possible organ domains interactions. Variables involved in significant bivariate relationships or interactions were candidates for inclusion in a multivariate model. Five additional variables were included in the multivariate model because of their possible confounding effect: perceived social support, age, education, perceived economic status and residual CIRS.

RESULTS

Significant differences in the PCS (p < 0.01) were found in 12 of the 14 CIRS organ domains. A significant difference in MCS was found only in the Psychiatric domain. In the multivariate analysis for the PCS, the CIRS domains Musculoskeletal, Neurological, and Psychiatric, had an independent direct impact on PCS while the Upper gastrointestinal, Vascular, Cardiac and Respiratory domains were involved in interactions. A multivariate model was not necessary for the mental component.

CONCLUSION

Vascular, Upper gastrointestinal and Musculoskeletal systems have strong negative effects on HRQOL. Among combinations of systems, the respiratory and cardiac combination is of particular concern because of a synergistic negative effect. This study paves the way for a future study with a bigger sample that could yield a model of wider generalizability.

Comorbidity in older surgical cancer patients: influence on patient care and outcome

Evidence is scarce about the influence of comorbidity on outcome of surgery, whereas this information is highly relevant for estimating the surgical risk of cancer patients, and for optimising pre-, peri- and postoperative care. In this paper, the prognostic role of increasing age and comorbid conditions in patients diagnosed with stage I-III colorectal, stage I-II NSCLC or stage I-III breast cancer between 1995 and 2004 in the southern part of the Netherlands is summarised. Almost all patients with stage I-III colon cancer or rectal cancer underwent surgery regardless of age or comorbidity. In contrast, the resection rate among elderly patients with stage I-II NSCLC was clearly lower than among younger patients and was significantly lower when COPD, cardiovascular diseases or diabetes were present. Among patients with stage I-III breast cancer, those aged 80 or older underwent less surgery, and the resection rate appeared to be lower when cardiovascular diseases or diabetes were present. Among patients with resected colorectal cancer, postoperative morbidity and mortality were higher among those undergoing emergency surgery, and also among those with reduced pulmonary function, cardiovascular disease or neurological comorbidity. Among those with resected NSCLC, postoperative morbidity and mortality were related to reduced pulmonary function or cardiovascular disease. Since surgery for breast cancer is low risk, elective surgery, morbidity and mortality were not higher for elderly or those with comorbidity. Among patients with colorectal or breast cancer, comorbidity in general, cardiovascular diseases, COPD, diabetes (only colon and breast cancer) and venous thromboembolism had a negative effect on overall survival, whereas the effect of comorbidity on survival of stage I-II NSCLC was less clear. Elderly and those with comorbidity (especially cardiovascular diseases and COPD) among colorectal cancer and NSCLC patients had more postoperative morbidity and mortality. Prospective randomised studies are needed for refining selection criteria for surgery in elderly cancer patients and for anticipation and prevention of complications.

Influences of hormone-based contraception on depressive symptoms in premenopausal women with major depression

OBJECTIVE

Hormone-based contraceptives affect mood in healthy women or in women with premenstrual dysphoric disorder (PMDD). No study has yet examined their association with mood in women with major depressive disorder (MDD). The purpose of this study was to determine whether estrogen-progestin combination or progestin-only contraceptives are associated with depression severity, function and quality of life, or general medical or psychiatric comorbidity in women with MDD.

METHODS

This analysis focused on a large population of female outpatients less than 40 years of age with non-psychotic MDD who were treated in 18 primary and 23 psychiatric care settings across the US, using data from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Baseline demographic and clinical information was gathered and compared between three groups based on hormonal use: combination (estrogen-progestin)(N=232), progestin-only (N=58), and no hormone treatment (N=948).

RESULTS

Caucasians were significantly more likely to use combined hormone contraception. Women on progestin-only had significantly more general medical comorbidities; greater hypersomnia, weight gain and gastrointestinal symptoms; and worse physical functioning than women in either of the other groups. Those on combined hormone contraception were significantly less depressed than those with no hormone treatment by the 16-item Quick Inventory of Depressive Symptomatology-Self-Rated. The combined hormone group also demonstrated better physical functioning and less obsessive-compulsive disorder (COCD) comorbidity than either of the other groups.

CONCLUSIONS

Synthetic estrogen and progestins may influence depressive and physical symptoms in depressed women.

Cognitive impairment in late-life generalized anxiety disorder

OBJECTIVE

This study sought to characterize cognitive functioning in elderly patients with generalized anxiety disorder (GAD), as compared with normal comparison subjects and patients with major depression.

METHODS

The cognitive functioning in GAD (N=19) was assessed with the Mattis Dementia Rating Scale and across specific domains of naming, executive ability, and memory, in comparison with late-life major depressive disorder (MDD; N=68) and versus no psychiatric illness (N=40).

RESULTS

In comparison to healthy normal comparison subjects, anxious subjects were impaired on measures of short-term and delayed memory. Depressed subjects also performed worse than normal comparison subjects on delayed memory, as well as in naming. Anxious subjects did not differ significantly from depressed subjects in any measure of cognitive function.

CONCLUSION

In this preliminary study, anxious subjects displayed cognitive impairments in short-term memory; while depressed patients compared to normal comparison subjects showed executive dysfunction and more general cognitive impairments not evident in anxious subjects. Studies of neuropsychological function in elderly anxious subjects may be informative in developing treatment interventions that mitigate cognitive dysfunction and illuminate the course of illness and underlying neural pathways.

Pain in depression: STAR*D study findings

BACKGROUND

Pain complaints commonly accompany major depressive disorder (MDD). However, whether patients with MDD and pain complaints differ from those without pain complaints is not well studied.

OBJECTIVE

The objective of this study was to compare depressed outpatients with and those without current pain complaints in terms of sociodemographic, clinical, and presenting symptom features.

METHODS

The baseline clinical and sociodemographic data of a large representative outpatient sample with nonpsychotic MDD (n=3745) enrolled in the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) study were collected. Baseline information on pain complaints was based on Item No. 25 (somatic pain) of the 30-item Inventory of Depressive Symptomatology-Clinician Rating (IDS-C(30)).

RESULTS

After adjusting for sex, depression severity (IDS-C(30) less Item No. 25), and general medical comorbidities (as measured by the Cumulative Illness Rating Scale total score), we found clinically meaningful differences between patients with and those without pain complaints. Younger, African American, Hispanic, and less educated patients were more likely to report pain complaints. In addition, those with pain complaints were more likely to report anxious features with irritable mood, sympathetic nervous system arousal, and gastrointestinal problems as well as poorer quality of life. Neither a more chronic course of illness nor suicidal ideation was associated with pain.

CONCLUSIONS

Pain complaints are common among outpatients with MDD and are associated with certain symptom features and poorer quality of life. However, the findings of this study suggest that depression accompanied by pain complaints does not increase the clinical psychiatric burden or chronicity of depression.

Disability in major depression related to self-rated and objectively-measured cognitive deficits: a preliminary study

BACKGROUND

Although major depression (MD) is associated with high levels of disability, the relationships between cognitive dysfunction and self-rated disability are poorly understood. This study examined the relationships between self-rated disability in persons with MD and both self-rated and objectively-measured cognitive functioning.

METHODS

Twenty-one persons with MD and 21 control participants underwent neuropsychological assessment and z-scores representing deviations from control performance were calculated and averaged across the domains of psychomotor speed, initial learning, memory retention and executive function. Self-ratings of cognitive deficits (SRCDs) were reported on a 6-point scale for overall rating of cognitive change, speed of thinking, concentration, and short-term memory. Disability scores for self-rated physical, mental-health and functional (ie. days out of role) disability were computed from the Brief-Disability Questionnaire and the SF-12 'mental component' subscale.

RESULTS

Persons with MD had a mean age of 53.9 years (SD = 11.0, 76% female) and had moderate to high depression severity (mean HDRS 21.7, sd = 4.4). As expected, depression severity was a strong predictor of physical (r = 0.7, p < 0.01), mental-health (r = 0.7, p < 0.01) and functional (r = 0.8, p < 0.001) disability on the Brief Disability Questionnaire. Additionally, for physical disability, both overall SRCDs and objectively-measured psychomotor speed continued to be independent significant predictors after controlling for depression severity, uniquely accounting for 13% and 16% of variance respectively. For functional disability scores, objectively-measured memory impairment and overall SRCDs were no longer significant predictors after controlling for depression severity.

CONCLUSION

While depression severity is associated with disability, the contributions of both self-rated and objectively-measured cognitive deficits are substantial and contribute uniquely and differentially to various forms of disability. Efforts directed at reducing cognitive deficits in depression may have the potential to reduce disability.

Response inhibition predicts poor antidepressant treatment response in very old depressed patients

OBJECTIVE

There have been mixed findings regarding the prognostic significance of age of onset, executive dysfunction, and hyperintensity burden on treatment outcome in late-life depression.

METHODS

Growth curve models were fit to data from the only 8-week, double-blind, placebo controlled trial of citalopram (20-40 mg/day) in patients aged 75 years and older with unipolar depression. Baseline assessment included Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (to determine age at onset), Stroop Color-Word Test (to assess the response inhibition component of execution dysfunction), and structural magnetic resonance imaging (to determine hyperintensity burden).

RESULTS

In the citalopram condition, patients with response inhibition (most impaired quartile) scored higher at endpoint than those without response inhibition. There were no effects for age of onset or hyperintensity load on response in the citalopram condition. In the placebo condition, patients with early-onset depression had higher depression scores at endpoint than patients with late-onset depression.

CONCLUSION

Only response inhibition, a fundamental executive function, predicted poor treatment response to antidepressant medication. Although patients with response inhibition also showed deficits in reaction time, adjusting for reaction time in our final response inhibition model did not substantively change the findings.

Gastrointestinal complications following abdominal sacrocolpopexy for advanced pelvic organ prolapse

OBJECTIVE

The aims of this secondary analysis of the "Colpopexy And Urinary Reduction Efforts" (CARE) study were to estimate the incidence of postoperative gastrointestinal complications and identify risk factors.

STUDY DESIGN

We prospectively identified gastrointestinal complications and serious adverse events (SAE) for 12 months after sacrocolpopexy. Two surgeons independently reviewed reports of ileus or small bowel obstruction (SBO).

RESULTS

Eighteen percent of 322 women (average age 61.3 years) reported "nausea, emesis, bloating, or ileus" during hospitalization and 9.8% at 6 weeks. Nineteen women (5.9%; CI 3.8%, 9.1%) had a possible ileus or SBO that generated SAE reports: 4 (1.2%, CI 0.5%,3.2%) were reoperated for SBO, 11 (3.4%, CI 1.9%,6.1%) were readmitted for medical management, and 4 had a prolonged initial hospitalization. Older age (P < .001) was a risk factor for ileus or SBO.

CONCLUSION

One in 20 women experiences significant gastrointestinal morbidity after sacrocolpopexy. This information will aid preoperative counseling.

The assessment of complexity in internal medicine patients. The FADOI Medicomplex Study

BACKGROUND

Although the number of elderly people is progressively increasing in the world, old and very old patients have been under-represented and understudied in trials evaluating the efficacy of chronic illness management models. The usual hospital indicators and practice guidelines do not consider the effects of complexity - co-morbidity, social support, functional and cognitive status, patient adherence to therapy, risk of adverse drug reactions - in these subjects. The aim of this observational, multi-centric cohort study was to carefully assess factors contributing to the complexity of care for patients admitted to internal medicine wards. This was done by evaluating the severity of disease and degree of stability at admission, co-morbidity, age-related impairments, and the need for discharge planning plus post-discharge support.

METHODS

A total of 386 patients from 11 internal medicine wards in Emilia-Romagna and Marche, Italy, enrolled in a given week were evaluated. At admission, the following variables were recorded: demographic characteristics, medical history, global clinical-social prognostic evaluation, co-morbidity, severity of illness, presence of shock or hemodynamic instability, coma, and frequencies and causes of unscheduled hospital re-admission.

RESULTS

Cancer, congestive heart failure, pneumonia, stroke, and chronic obstructive pulmonary disease were the most frequent primary diagnoses. The complexity of our case study was characterized by several concomitant diseases. Over 50% of the patients were considered severe or more than severe, and over 20% extremely severe, with very high co-morbidity indices and illness severity scores. Some 55% of our patients were in need of partial or total care; 10% had some speech impairment, and 63% needed in-home health care after hospital discharge.

CONCLUSIONS

The increasing numbers of elderly patients admitted to internal medicine departments suggests the need for a chronic illness management model, integrating gerontological and geriatric care to improve outcomes. For effective care, future protocols need to take a multi-dimensional, interdisciplinary approach to these patients and to develop a coordinated, integrated plan for treatment and long-term follow-up.

Depression is associated with low plasma Abeta42 independently of cardiovascular disease in the homebound elderly

BACKGROUND

Depression often precedes the onset of Alzheimer's disease (AD) before the appearance of cognitive symptoms. Plasma Amyloid-beta peptide 42 (Abeta42) declines before and soon after the onset of AD, yet the relationship between plasma Abeta42 and depression is unclear.

METHODS

We used 515 homebound elders aged 60 and older in a population-based, cross-sectional study to investigate associations between plasma Abeta levels and depression with and without cardiovascular co-morbidities. Depression was evaluated by using the Center for Epidemiological Studies Depression (CES-D) scale. Plasma Abeta40 and Abeta42 were measured.

RESULTS

The elderly with depression had lower plasma Abeta42 (median: 15.3 vs. 18.9, p = 0.008) than those without depression. The CES-D score was inversely associated with plasma Abeta42 (p = 0.001) in subjects with no cardiovascular disease (CVD); however, in the presence of CVD, this association did not exist. Low plasma Abeta42 (OR = 0.41, p = 0.007) and the presence of CVD (OR = 1.84, p = 0.005) were independently associated with depression after adjusting for the confounders of age, stroke and apolipoprotein E4.

CONCLUSIONS

Depressive symptoms are associated with low plasma Abeta42 independently of CVD. Prospective studies are needed to determine whether depression associated with low plasma Abeta42 is a separate depression subtype that could predict the onset of AD.

The Effect of Age on Short-Term Outcomes After Abdominal Surgery for Pelvic Organ Prolapse

OBJECTIVES

To compare perioperative morbidity and 1-year outcomes of older and younger women undergoing surgery for pelvic organ prolapse (POP).

DESIGN

Prospective ancillary analysis.

SETTING

Academic medical centers in National Institutes of Health, National Institute of Child Health and Human Development Colpopexy and Urinary Reduction Study.

PARTICIPANTS

Women with POP and no symptoms of stress incontinence.

INTERVENTION

Abdominal sacrocolpopexy with randomization to receive Burch colposuspension for treatment of possible occult incontinence or not.

MEASUREMENTS

Perioperative complications and Pelvic Organ Prolapse Quantification and quality-of-life (QOL) questionnaires (Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and Medical Outcomes Study Short-Form Health Survey (SF-36) preoperatively, immediately postoperatively, and 6 weeks and 3 and 12 months postoperatively).

RESULTS

Three hundred twenty-two women aged 31 to 82 (21% aged > or =70), 93% white. Older women had higher baseline comorbidity (P<.001) and more severe POP (P=.003). Controlling for prolapse stage and whether Burch was performed, there were no age differences in complication rates. Older women had longer hospital stays (3.1+/-1.0 vs 2.7+/-1.5 days, P=.02) and higher prevalence of incontinence at 6 weeks (54.7% vs 37.2%, P=.005). At 3 and 12 months, there were no differences in self-reported incontinence, stress testing for incontinence, or prolapse stage. Improvements from baseline were significant on all QOL measures but with no age differences.

CONCLUSION

Outcomes of prolapse surgery were comparable between older and younger women except that older women had slightly longer hospital stays.

Neuroanatomical characteristics of geriatric apathy and depression: a magnetic resonance imaging study

OBJECTIVE

Apathy is one of the most common late-life neuropsychiatric syndromes. The objective of our study was to examine the neuroanatomical correlates of apathy in older subjects with and without geriatric major depression (MDD).

METHODS

Eighty-four subjects (43 patients with MDD and 41 normal comparison subjects) underwent comprehensive neuropsychiatric examination, physical examination, and high-resolution magnetic resonance imaging (MRI) brain scans on a 1.5T GE MRI scanner. Apathy was assessed using the Apathy Evaluation Scale. MRI image analyses included cortical surface extraction, tissue segmentation, and cortical parcellation methods to measure the gray and white matter volumes in two prefrontal subregions: the anterior cingulate and orbitofrontal cortex.

RESULTS

The depressed group had smaller orbitofrontal gray matter volumes compared to the age-matched normal comparison group. The severity of apathy was associated with the decreased gray matter volume in the right anterior cingulate gray matter volumes using partial correlation and regression analyses after controlling for age, sex, and diagnosis.

CONCLUSION

Apathy and depression were associated with different anatomical correlates in the prefrontal regions implicated in the regulation of cognition and emotion. Our findings offer new understanding of the neuroanatomical characteristics of apathy and depression in late life, and have broad implications for the neurobiology of behavior.

Constructing evidence-based treatment strategies using methods from computer science

This paper details a new methodology, instance-based reinforcement learning, for constructing adaptive treatment strategies from randomized trials. Adaptive treatment strategies are operationalized clinical guidelines which recommend the next best treatment for an individual based on his/her personal characteristics and response to earlier treatments. The instance-based reinforcement learning methodology comes from the computer science literature, where it was developed to optimize sequences of actions in an evolving, time varying system. When applied in the context of treatment design, this method provides the means to evaluate both the therapeutic and diagnostic effects of treatments in constructing an adaptive treatment strategy. The methodology is illustrated with data from the STAR*D trial, a multi-step randomized study of treatment alternatives for individuals with treatment-resistant major depressive disorder.

Cross-sectional validation of the Aging Perceptions Questionnaire: a multidimensional instrument for assessing self-perceptions of aging

BACKGROUND

Self-perceptions of aging have been implicated as independent predictors of functional disability and mortality in older adults. In spite of this, research on self-perceptions of aging is limited. One reason for this is the absence of adequate measures. Specifically, there is a need to develop a measure that is theoretically-derived, has good psychometric properties, and is multidimensional in nature. The present research seeks to address this need by adopting the Self-Regulation Model as a framework and using it to develop a comprehensive, multi-dimensional instrument for assessing self-perceptions of aging. This study describes the validation of this newly-developed instrument, the Aging Perceptions Questionnaire (APQ).

METHODS

Participants were 2,033 randomly selected community-dwelling older (+65 yrs) Irish adults who completed the APQ alongside measures of physical and psychological health. The APQ assesses self-perceptions of aging along eight distinct domains or subscales; seven of these examine views about own aging, these are: timeline chronic, timeline cyclical, consequences positive, consequences negative, control positive, control negative, and emotional representations; the eighth domain is the identity domain and this examines the experience of health-related changes.

RESULTS

Mokken scale analysis showed that the majority of items within the views about aging subscales were strongly scalable. Confirmatory factor analysis also indicated that the model provided a good fit for the data. Overall, subscales had good internal reliabilities. Hierarchical linear regression was conducted to investigate the independent contribution of APQ subscales to physical and psychological health and in doing so determine the construct validity of the APQ. Results showed that self-perceptions of aging were independently related to physical and psychological health. Mediation testing also supported a role for self-perceptions of aging as partial mediators in the relationship between indices of physical functioning and physical and psychological health outcomes.

CONCLUSION

Findings support the complex and multifaceted nature of the aging experience. The good internal reliability and construct validity of the subscales suggests that the APQ is a promising instrument that can enable a theoretically informed, multidimensional assessment of self-perceptions of aging. The potential role of self-perceptions of aging in facilitating physical and psychological health in later life is also highlighted.

Accuracy of life tables in predicting overall survival in candidates for radiotherapy for prostate cancer

PURPOSE

To test the accuracy of life tables (LTs) in predicting survival in men treated with radiotherapy for localized prostate cancer.

METHODS AND MATERIALS

We selected the records of 3,176 patients treated with radiotherapy and who had no clinical evidence of disease relapse. Life table-derived life expectancy (LE) was defined for every individual using a population-specific LT. Age, Charlson Comorbidity Index (CCI), and LT-derived LE were then used as predictors of overall mortality in Cox regression models. Predictive accuracy (PA) was estimated with the Harrell's concordance index and was internally validated with 200 bootstrap resamples.

RESULTS

The actuarial median survival was 4.7 years (mean, 6.4 years). At radiotherapy, median age was 70.6 years, median CCI was 2, and median LT-derived LE was 12 years. All variables were statistically significant predictors of overall mortality (all p values <0.001). Age (PA, 60.2%), CCI (PA, 60.1%), and LT-derived LE (PA, 60.2%) were equally accurate. Finally, when age and CCI were combined (PA, 63.2%), both variables provided more accurate mortality predictions than either variable alone (all p values = 0.01).

CONCLUSIONS

Life tables have a limited ability to predict LE in patients treated with radiotherapy for prostate cancer. We, therefore, recommend the use of multivariate prognostic models that integrate several variables, such as at least age and comorbidities, to estimate LE. This might help to improve LE estimation during prostate cancer treatment decision making.

Predictive validity of neuropsychiatric subgroups on nursing home placement and survival in patients with Alzheimer disease

OBJECTIVE

The aim of the study was to conceptualize neuropsychiatric symptoms in patients with Alzheimer disease as distinct symptom profiles with differential disease outcomes. Two outcomes of interest in the study were nursing home placement and survival.

METHOD

Cluster analysis was used to categorize 122 patients with Alzheimer disease based on their neuropsychiatric symptoms as assessed by the Neuropsychiatric Inventory. Both the presence as well as the severity and frequency of symptoms were considered. After identification of the subgroups, the predictive validity of the categorization was tested on time to nursing home placement and time to death over a three-year period. Cox proportional hazard models were used to perform survival analysis. Important covariates such as severity of cognitive and functional impairments, comorbid medical conditions, presence of parkinsonism, and marital status were adjusted at baseline.

RESULTS

Based on the presence of neuropsychiatric symptoms, three subgroups were identified: minimally symptomatic, highly symptomatic, and affective/apathetic. Over a three-year period, the highly symptomatic group had an increased risk of nursing home placement. In addition, the rates of survival were significantly lower for the highly symptomatic and the affective/apathetic subgroups. Based on the severity and frequency of symptoms, two-cluster and four-cluster solutions were produced. The groupings based on severity and frequency of symptoms predicted significant differential outcomes in survival and nursing home placement.

CONCLUSIONS

Neuropsychiatric subgroups were able to predict differential outcomes and identify those with an increased risk for a worse prognosis. The findings were discussed through their research and clinical implications.

Comparison of quality of life measures in a depressed population

Measures of quality of life have been increasingly used in clinical trials. When designing a study, researchers must decide which quality of life measure to use. Some literature provides guidance through general recommendations, though lacks quantitative comparisons. In this report, 2 general quality of life measures, the 12-Item Short Form Health Survey (SF-12) and the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), are compared in a depressed population. STAR*D data were used to analyze the associations among the SF-12 and the Q-LES-Q. Each measure covers 6 domains, overlapping on 5 (health, self-esteem/well-being, community/productivity, social/love relationships, leisure/creativity), with the SF-12 addressing family and the Q-LES-Q addressing living situations. Strong item-by-item associations exist only between the Q-LES-Q and the SF-12 physical health items. The 2 measures overlap on the domains covered while the lack of correlation between the 2 measures may be attributed to the perspective of each question as the Q-LES-Q measures satisfaction while the SF-12 measures the patient's perception of function.

Preadult onset vs. adult onset of major depressive disorder: a replication study

OBJECTIVE

In the first 1500 participants with major depressive disorder (MDD) that entered the sequenced treatment alternatives to relieve depression (STAR*D) study, those with preadult onset MDD were more likely to be women and to have a more chronic, severe and disabling form of depression than those with adult onset MDD. This study seeks to replicate these findings.

METHOD

The second wave of STAR*D enrollees included 2541 out-patients with MDD, divided into preadult (before age 18) and adult (age 18 or later) onset groups.

RESULTS

Participants with a preadult onset of MDD (38%) were younger, ill for longer and more likely to be women than those with adult onset MDD (62%). After adjusting for age, duration of illness and gender, participants with preadult onset MDD also had higher rates of family history of depression, more past suicide attempts, and lower rates of obsessive compulsive and panic disorder.

CONCLUSION

Preadult onset MDD may be associated with a more familial form of depression with more suicidality than adult onset MDD.

Emergence, persistence, and resolution of suicidal ideation during treatment of depression in old age

INTRODUCTION

To determine the rate and clinical correlates of emergent, persistent, and resolved suicidal ideation during treatment of major depression in the elderly.

METHODS

Based on the course of suicidal ideation before and during 12 weeks of antidepressant treatment, we classified 437 elderly patients (234 treated with paroxetine; 203 with nortriptyline) as either non-suicidal or as having "emergent", "persistent", or "resolved" suicidality. We compared the four groups on pretreatment demographic and clinical measures and with respect to depression, anxiety, and akathisia during treatment.

RESULTS

Rates of emergent, persistent, and resolved suicidality were 7.8%, 12.6%, and 15.6%, respectively. Patients with persistent suicidal ideation were more likely to have recurrent depression than non-suicidal patients or patients whose suicidality resolved with treatment. At the start of treatment, patients in all three suicidal groups had lower self-esteem than non-suicidal patients. During the course of treatment, emergent suicidality was not associated with akathisia, nor did rates of emergent suicidality differ between paroxetine- and nortriptyline-treated patients. While at baseline the levels of depression and anxiety and agitation were similar in the four groups, patients with resolved suicidality had a favorable treatment response, while patients with emergent and persistent suicidality were more likely to maintain higher depression scores and had higher levels of anxiety and agitation during treatment.

DISCUSSION

Emergence of suicidal ideation is not common but is clinically significant during treatment of late-life depression and may signal more difficult-to-treat-depression.

The characteristics of fatigue in an older primary care sample

BACKGROUND

Primary care studies of younger adults have reported fatigue to be common and etiologically heterogeneous with both physical and psychological associations. This has led to considerable debate about whether fatigue may present independently of psychological disorder. Somatic symptoms in older people have been assumed to be almost entirely physical in origin.

AIMS

To determine the characteristics of fatigue and its relationship with psychological disorder in older primary care attenders.

METHOD

Ambulatory primary care patients aged 60 years and over completed self-report questionnaires and psychiatric interview at baseline and at 12 months.

RESULTS

The overall prevalence of fatigue was 27.4% with most, but not all, cases being comorbid with psychological disorder. Psychological disorder (OR, 8.43; 95% CI, 2.98-23.88) was a greater predictor of fatigue than physical illness (OR, 4.74; 95% CI, 1.63-13.85). Neither a tendency for fatigue to evolve into psychological disorder, nor vice versa, was observed longitudinally (overall kappa, 0.68; P<.001).

CONCLUSIONS

Fatigue is common in older primary care attenders and is not associated with physical illness alone. Despite the high rate of comorbidity with psychological disorder, independent and longitudinally stable forms of fatigue did present. The overall findings suggest that while fatigue does overlap with psychological phenomena, there may also be distinct forms of fatigue.

Continuity of care and general wellbeing of patients with comorbidities requiring joint replacement

AIM

The aim of this paper is to examine the continuity of care and general wellbeing of patients with comorbidities undergoing elective total hip or knee joint replacement.

BACKGROUND

Advances in medical science and improved lifestyles have reduced mortality rates in most Western countries. As a result, there is an ageing population with a concomitant growth in the number of people who are living with multiple chronic illnesses, commonly referred to as comorbidities. These patients often require acute care services, creating a blend of acute and chronic illness needs. For example, joint replacement surgery is frequently performed to improve impaired mobility associated with osteoarthritis.

METHOD

A purposive sample of twenty participants with multiple comorbidities who required joint replacement surgery was recruited to obtain survey, interview and medical record audit data. Data were collected during 2004 and 2005.

FINDINGS

Comorbidity care was poorly co-ordinated prior to having surgery, during the acute care stay and following surgery and primarily entailed prescribed medicines. The main focus in acute care was patient throughput following joint replacement surgery according to a prescribed clinical pathway. General wellbeing was less than optimal: participants reported pain, fatigue, insomnia and alterations in urinary elimination as the chief sources of discomfort during the course of the study.

CONCLUSION

Continuity of care of comorbidities was lacking. Comorbidities affected patient general wellbeing and delayed recovery from surgery. Acute care, clinical pathways and the specialisation of medicine and nursing subordinated the general problem of patients with comorbidities. Systems designed to integrate and co-ordinate chronic illness care had limited application in the acute care setting. A multidisciplinary, holistic approach is required. Recommendations for further research conclude this paper.

Cognitive functioning and instrumental activities of daily living in late-life bipolar disorder

OBJECTIVE

The authors report on the relationship between cognitive functioning and instrumental activities of daily living (IADLs) in elderly, clinically euthymic adults with bipolar disorder.

METHODS

Twenty patients with bipolar disorder (age range: 61-86 years) were administered comprehensive neuropsychologic testing. Structured in-home performance-based assessments of IADLs were performed in 19 of these patients.

RESULTS

Relative to age-equated comparators, bipolar subjects performed worse in information-processing speed and executive functioning. IADL performance was strongly correlated with these cognitive domains.

CONCLUSIONS

In euthymic elderly patients with bipolar disorder, decrements in information processing speed and executive functioning characterize cognitive function and are associated with poorer IADL performance.

Comorbidity in patients with cancer: prevalence and severity measured by cumulative illness rating scale

Comorbidity is defined as the presence of one or more diseases in addition to an index disease. In elderly people, the number and severity of comorbidity increase with age. We report the comorbidity data of 536 patients treated as in-patients: 231 elderly cancer patients (ECP), 172 younger cancer patients (YCP) and 133 elderly patients admitted for non-cancer reasons (EMP). Comorbidity was assessed with the cumulative illness rating scale geriatric version (CIRS-G). Data on number of affected organ systems (levels 1-4), number of affected organ systems with severe disease (levels 3-4), and sum score of levels per patient are reported. The number of comorbidities increases with age. A 76% of ECP, 51% of YCP, and 79% of EMP have severe comorbidity. Palliative treatment approach is not associated with higher levels of comorbidity in ECP. Vascular disorders were the most common comorbidity. The difficulty to rate haematological comorbidity in cancer patients is reflected. This is the first report on detailed results of assessment of comorbidity measured by CIRS-G in cancer patients. In addition, we provide a comparison to an elderly group of patients admitted for non-cancer reasons.