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

A joined analysis of two European Organization for the Research and Treatment of Cancer (EORTC) studies to evaluate the role of pegylated liposomal doxorubicin (Caelyx™) in the treatment of elderly patients with metastatic breast cancer

We have performed a retrospective analysis to evaluate the impact of age, using a 70 year cutoff, on the safety and efficacy of pegylated liposomal doxorubicin (Caelyx) given at 60 mg/m(2) every 6 weeks (treatment A) or 50 mg/m(2) every 4 weeks (treatment B) to 136 metastatic breast cancer patients in two EORTC trials, of whom 65 were 70 years of age or older. No difference in terms of toxicity was observed between younger and older patients treated with the 4-week schedule, while a higher incidence of hematological toxicity, anorexia, asthenia, and stomatitis was observed in older patients when the 6-week schedule was used. Antitumor activity was not affected by age. In the older cohort of patients, no dependence was found between the incidence of grade 3-4 toxicity or antitumor activity and patients' baseline performance status, number and severity of comorbidities, or number of concomitant medications. The higher therapeutic index of Caelyx 50 mg/m(2) every 4 weeks makes it, of the two dose schedules investigated, the preferred regimen in the elderly.

Validation of the Cumulative Illness Rating Scale (CIRS) in hospitalized nonagenarians

This is a retrospective analysis of patients aged 90-99 years, admitted over a 6-month period to a district hospital. One hundred three patients were included in the study with an average age of 92 years and a male to female ratio of 1:3. Fifty-five percent of the patients hospitalized came from nursing care facilities. Comparisons were made of patient characteristics from nursing homes and the community. The physical burden of illness was measured by the CIRS, Illness Severity Index (SI), and Co-morbidity Index (CI). The average length of stay was 6.3 days for those from nursing care facilities and 10.2 days from the community as compared with 3.3 days for total hospital in-patients. Excluding deceased patients there was a significant (p < 0.05) correlation between patient's CIRS to length of stay in hospital but was equivocal for SI and CI. There were no association between patient's CIRS, SI, and CI to mode of referral and residence. The mortality rate for this group was 13% as compared with the hospital rate of 10.2%. CIRS, SI, and CI were useful in distinguishing the mortally ill from the morbidly ill; otherwise there were no differences, between patients who hail from nursing care facilities or from the community and whether they were referred by carers, nursing staff, medical practitioners/specialists or themselves. There were significant differences in the CIRS scores between deceased and survivors indicating CIRS is potentially useful tool in predicting outcome. The SI and CI composites performed equally well in predicting outcome.

The cognitive effects of electroconvulsive therapy in community settings

Despite ongoing controversy, there has never been a large-scale, prospective study of the cognitive effects of electroconvulsive therapy (ECT). We conducted a prospective, naturalistic, longitudinal study of clinical and cognitive outcomes in patients with major depression treated at seven facilities in the New York City metropolitan area. Of 751 patients referred for ECT with a provisional diagnosis of a depressive disorder, 347 patients were eligible and participated in at least one post-ECT outcome evaluation. The primary outcome measures, Modified Mini-Mental State exam scores, delayed recall scores from the Buschke Selective Reminding Test, and retrograde amnesia scores from the Columbia University Autobiographical Memory Interview-SF (AMI-SF), were evaluated shortly following the ECT course and 6 months later. A substantial number of secondary cognitive measures were also administered. The seven sites differed significantly in cognitive outcomes both immediately and 6 months following ECT, even when controlling for patient characteristics. Electrical waveform and electrode placement had marked cognitive effects. Sine wave stimulation resulted in pronounced slowing of reaction time, both immediately and 6 months following ECT. Bilateral (BL) ECT resulted in more severe and persisting retrograde amnesia than right unilateral ECT. Advancing age, lower premorbid intellectual function, and female gender were associated with greater cognitive deficits. Thus, adverse cognitive effects were detected 6 months following the acute treatment course. Cognitive outcomes varied across treatment facilities and differences in ECT technique largely accounted for these differences. Sine wave stimulation and BL electrode placement resulted in more severe and persistent deficits.

Does depression, apathy or cognitive impairment reduce the benefit of inpatient rehabilitation facilities for elderly hip fracture patients?

OBJECTIVE

Depression, apathy (amotivation) and cognitive impairment are common comorbidities in hip fracture patients, which may adversely affect functional outcome of rehabilitation. We examined whether postfracture measures of mood, motivation or cognition are associated with rehabilitation outcome (defined as functional improvement) in inpatient rehabilitation facilities (IRFs), as compared to skilled nursing facilities (SNFs).

METHODS

This prospective study examined elderly patients who received surgical fixation for hip fracture and then received post-acute rehabilitation at an IRF or an SNF. Subjects were characterized at baseline for depression using the Hamilton Rating Scale for Depression, apathy/amotivation using the Apathy Evaluation Scale and mild-moderate cognitive impairment using the Mini-Mental Status Examination. Functional recovery was measured over 12-week follow-up using the Functional Independence Measure.

RESULTS

Fifty-eight subjects were discharged from acute care to an IRF and 39 to an SNF. Patients with depression, apathy or cognitive impairment who received rehabilitation at an IRF had significantly better functional outcomes than similarly impaired patients at SNFs, and similar outcomes such as nondepressed, motivated and cognitively intact elderly at IRFs.

CONCLUSION

These findings suggest that depression, amotivation or mild-moderate cognitive impairment after hip fracture do not reduce the benefit of post-acute rehabilitation in an IRF.

Which benefit from adding gemcitabine to vinorelbine in elderly (≥70 years) women with metastatic breast cancer? Early interruption of a phase II study

BACKGROUND

Since vinorelbine and gemcitabine are both active in breast cancer with moderate toxicity, in 2002 we started a phase II trial with a combination regimen in elderly patients.

PATIENTS AND METHODS

To evaluate complete plus partial response rates and toxicity of first-line vinorelbine 25 mg/m2 plus gemcitabine 1000 mg/m2 on days 1 and 8, every 3 weeks, in women>or=70 years with advanced breast cancer and measurable lesions. All patients underwent multidimensional geriatric assessment before enrollment. A two-step design was applied, and the trial would be completed if an overall response rate>or=30% was obtained with a grade 3-grade 4 (G3-G4) toxicity rate<or=25% (excluding neutropenia) in the first step.

RESULTS

Twelve eligible patients had a median age of 74 years. At MGA, eight patients were fit, three vulnerable, one frail due to major depression; only two patients had G3 comorbidities according to Cumulative Illness Rating Scale-Geriatric. Seventy-five percent of patients had visceral disease. We obtained only one partial remission (11.1%) and six stabilizations of disease in nine assessable patients, with a time to progression of 3 months. Three patients (25%) experienced G3 neutropenia, and three patients (25%) developed G3 anemia (one patient) and G3 gastrointestinal toxicity (two patients).

CONCLUSIONS

The promising response rates obtained with this combination by other authors could not be confirmed in our small cohort of older women with breast cancer, therefore the trial was prematurely terminated. We do not recommend the co-administration of gemcitabine to vinorelbine in women>or=70 years outside the setting of controlled clinical trials.

A Multicomponent Nonpharmacological Intervention Improves Activity Rhythms Among Nursing Home Residents With Disrupted Sleep/Wake Patterns

BACKGROUND

Sleep and circadian rhythms are disrupted among many nursing home (NH) residents. We examined the impact of a multicomponent nonpharmacological intervention on 24-hour rest/activity rhythms among long-stay NH residents.

METHODS

The study was a randomized controlled trial in which, following a 3-day baseline, participants received 5 days of either usual care (control condition) or the active intervention. The intervention combined increased exposure to outdoor bright light, efforts to keep residents out of bed during the day, structured physical activity, institution of a bedtime routine, and efforts to reduce nighttime noise and light in residents' rooms. For 100 residents with baseline and follow-up wrist actigraphy data (mean age = 87 years; 76% women), rest/activity rhythms were modeled to determine the rhythm acrophase (peak time), nadir (trough time), midline estimating statistic of rhythm (MESOR) (midpoint), amplitude (height of peak), slope, and the rest period/active period ratio (alpha).

RESULTS

The intervention led to an increase in the duration of the "active" portion of the rhythm, which was primarily accounted for by a shift in the rest/activity rhythm rise to an earlier time. Findings persisted when analyses were adjusted for age, cognitive functioning, medical comorbidities, and behavioral disturbances.

CONCLUSIONS

These findings suggest that the intervention may effectively improve the robustness of rest/activity rhythms in NH residents. Further research is needed to examine the impact of similar interventions on other measures of circadian rhythms (e.g., body temperature, melatonin) among NH residents.

The relationship between pain and mental flexibility in older adult pain clinic patients

OBJECTIVE

Persistent pain and cognitive impairment are each common in older adults. Mental flexibility, memory, and information-processing speed may be particularly vulnerable in the aging brain. We investigated the effects of persistent pain on these cognitive domains among community-dwelling, nondemented older adults.

SETTING

Older Adult Pain Management Program.

DESIGN

A total of 56 new patients (mean age 76.1 years) were recruited to describe 1) rates of persistent pain conditions and pain intensity; 2) cognition (mental flexibility, short-term memory, and psychomotor speed); 3) severity of depression; and 4) sleep quality. All patients had nonmalignant pain for at least 3 months. Pain intensity was measured with the McGill Pain Questionnaire and depression severity with the 17-item Hamilton Rating Scale for Depression. Cognition was assessed with 1) Mini-Mental State Exam; 2) Number-Letter-Switching and Motor Speed subtests of the Delis-Kaplan Executive Function System Trail Making Test; 3) Digit Symbol Subtest (DSST) of the Wechsler Adult Intelligence Scales-III; and 4) free and paired recall of the DSST digit-symbol pairs. Multiple linear regression modeled whether these variables predicted poorer cognitive outcomes, after adjusting for the effects of opioids, sleep impairment, depression, medical comorbidity, and years of education.

RESULTS

In univariate analysis, pain severity was associated with a greater impairment on number-letter switching (r = -0.42, P = 0.002). This association remained after adjusting for the effects of depression, sleep, medical comorbidity, opioid use, and years of education (t = -1.97, P = 0.056).

CONCLUSIONS

In community dwelling older adults, neither pain nor mood was associated with measures of short-term memory or information-processing speed. However, pain severity was associated with decreased performance on a test of number-letter switching, indicating a relationship between pain and mental flexibility.

What clinical and symptom features and comorbid disorders characterize outpatients with anxious major depressive disorder: a replication and extension

OBJECTIVE

We previously found that 46% of the first 1450 outpatients with depression participating in the multicentre Sequenced Treatment Alternatives to Relieve Depression (STAR*D) project qualified for the designation of anxious depression. This study was designed to replicate and extend our initial findings in a subsequent, larger cohort of outpatient STAR*D participants with nonpsychotic major depressive disorder (MDD).

METHODS

Baseline clinical and sociodemographic data were collected on 2337 consecutive STAR*D participants. A baseline 17-item Hamilton Depression Rating Scale Anxiety-Somatization factor score of 7 or higher was designated as anxious depression. We identified concurrent Axis I disorders with the Psychiatric Diagnostic Screening Questionnaire (PDSQ), using a 90% specificity threshold. Depressive symptoms were assessed by clinical telephone interview with the 30-item Inventory of Depressive Symptomatology-Clinician-Rated (IDS-C30).

RESULTS

The prevalence of anxious depression in this population was 45.1%. Patients with anxious MDD were significantly more likely to be in primary care settings and to be women, nonsingle, unemployed, Hispanic, less educated, and suffering from severe depression, both before and after adjustment for overall depression severity. Patients with anxious depression were significantly more likely to meet PDSQ thresholds for generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, agoraphobia, hypochondriasis, and somatoform disorder, both before and after adjusting for baseline depression severity. Individuals with anxious depression were also significantly less likely to endorse IDS-C30 items concerning atypical features and were significantly more likely to endorse items concerning melancholic-endogenous depression features, both before and after adjusting for baseline depression severity.

CONCLUSIONS

This study clearly replicates our previous STAR*D findings and supports the notion that anxious depression may be a valid diagnostic subtype of MDD, with distinct psychiatric comorbidities and clinical and sociodemographic features.

Impact of prior treatment exposure on response to antidepressant treatment in late life

OBJECTIVE

The objective of this study was to describe the correlates of prior antidepressant exposure and its association with response to protocolized treatment in older patients with major depression.

METHODS

Based on their prior antidepressant treatment exposure, 193 elderly patients with a major depressive episode were divided into three groups: those with no prior treatment for their current episode (not treated [TN]), those with antidepressant trials of inadequate dose or duration ("treatment-inadequate" [TI]), and those with at least one adequate trial but persisting depression ("treatment-resistant" [TR]). All patients then received protocolized treatment with interpersonal psychotherapy (IPT) and paroxetine plus pharmacologic augmentation if needed. The demographic, clinical, and outcome information were compared among these three groups.

RESULTS

Approximately one-third of the patients referred to the study had been adequately treated (TR), one-third had been inadequately treated (TI), and one-third were not treated for the current episode (TN). Treatment completion rates and reasons for dropping out did not differ statistically among TR, TI, and TN patients. TR patients took longer to respond (13.0 weeks) than either TI or TN patients (7.6 and 8.0 weeks, respectively). TR and TI patients had lower response rates (67% and 71%) than TN patients (86%).

CONCLUSIONS

Prior treatment exposure is an important correlate of course and outcome in late-life depression. Most TR and TI patients eventually respond, but TR patients may require more intensive and longer courses of treatment than TI and TN patients.

Dietary intake of unsaturated fatty acids and age-related cognitive decline: A 8.5-year follow-up of the Italian Longitudinal Study on Aging

There is evidence from a population-based study of an inverse relationship between monounsaturated fatty acids (MUFA) energy intake and age-related cognitive decline (ARCD), while high polyunsaturated fatty acids (PUFA) intake was positively associated with cognitive impairment in elderly subjects. We investigated the possible role of MUFA and PUFA on age-related cognitive changes. A population-based, prospective study was carried out on 278, 186, and 95 nondemented elderly subjects (65-84 years) evaluated for global cognitive functions (Mini-Mental State Examination, MMSE) at the first (1992-1993), second (1995-1996), and third survey (2000-2001), respectively, from the randomized cohort of Casamassima, Bari, Italy (n=704), one of the eight centers of the Italian Longitudinal Study on Aging (ILSA). MUFA and PUFA intakes were assessed at baseline with a semi-quantitative food frequency questionnaire. High MUFA and PUFA energy intakes and total energy intake were significantly associated with a better cognitive performance in a 8.5-year follow-up. In this prospective population-based study on older nondemented subjects with a typical Mediterranean diet, high MUFA and PUFA intakes appeared to be protective against ARCD.

Depression, physical impairment, and treatment of depression in chronic heart failure

BACKGROUND AND RESEARCH OBJECTIVE

This study examines the contribution of attitudes about impairment to the relation between depression and physical impairment in patients with heart failure. It also describes the current status of antidepressant treatment in a sample of outpatients with heart failure.

SUBJECTS AND METHODS

A total of 32 depressed and 51 nondepressed patients with heart failure were recruited while seeking heart failure treatment in an outpatient heart failure or family practice clinic. Medical, functional, cognitive, and psychological measures were administered at baseline. Depression measures were readministered to the 32 depressed patients at 8, 16, and 24 weeks after the baseline interview.

RESULTS AND CONCLUSIONS

Attitudes about impairment and perceived social support were the strongest cross-sectional correlates of depression. The strong association between physical impairment and depression was no longer significant after controlling for attitudes about impairment. In addition, attitudes about impairment predicted chronicity of depressive symptoms longitudinally after controlling for baseline depressive symptom severity. The relation between physical impairment and depression in heart failure is strongly related to how patients cope with impairment. These results call for the development of additional interventions to treat depression that focus on the emotional adjustment to physical impairment.

Cardiovascular changes associated with venlafaxine in the treatment of late-life depression

BACKGROUND

Potential cardiovascular side effects from venlafaxine-XR must be considered when prescribing this medication, especially in geriatric patients, who often present with comorbid medical conditions.

METHODS

Participants age 60 and older with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of a major depressive episode without psychotic features were treated openly with venlafaxine-XR for 12 weeks during which venlafaxine-XR was titrated based on tolerability and response according to predefined guidelines. Sitting and standing blood pressures and heart rates were measured. A 12-lead electrocardiogram was obtained at baseline and at week 12.

RESULTS

Sixty-two participants started treatment; 59 completed at least two weeks of the 12-week study. The mean final dose of venlafaxine-XR was 195.5 mg/day (standard deviation: 72.2). Twenty-four percent (95% confidence interval [CI]: 7.3%-40.7%) of initially normotensive participants and 54% (95% CI: 34.3%-74%) of those with preexisting hypertension experienced an increase in blood pressure. Twenty-nine percent (95% CI: 14.6%-43.4%) of participants developed orthostatic hypotension. Two participants experienced a clinically significant increase in QTc interval. One participant reported new-onset mild dizziness, whereas four participants reported new-onset tachycardia or palpitation. Overall, 17 unique participants (28.8%; 95% CI: 17.3%-40.4%) experienced a new-onset cardiovascular problem, potentially related to the study medication.

CONCLUSION

Overall, venlafaxine-XR was well tolerated. However, similar to previous reports, venlafaxine-XR was associated with some undesirable cardiovascular effects in some of the participants. Systematic monitoring of cardiovascular parameters during treatment with venlafaxine-XR should be strongly recommended, especially in the elderly.

White matter and subcortical gray matter lesion volume changes and late-life depression outcome: a 4-year magnetic resonance imaging study

BACKGROUND

Cross-sectional studies have shown that late-onset depression is associated with larger deep white matter lesions (WMLs) and subcortical gray matter lesions (GMLs). In a longitudinal analysis, we examined changes in deep WMLs and subcortical GMLs in older depressed and nondepressed subjects over a 4-year period.

METHODS

Brain magnetic resonance imaging (MRI) scans were obtained on 164 depressed and 126 healthy subjects aged 60 years or older at baseline, and 2 and 4 years after recruitment. WMLs and GMLs were measured using a semiautomated technique. We used repeated-measures analysis of covariance to determine cross-sectional lesion volume differences, whether lesion volume changes differed between patients and controls, and the effect of lesion volume changes on outcome in late-life depression.

RESULTS

Mean volumes of lesions for the depressive group were 6.51, 8.18 and 7.75 cm2 for WMLs and 0.23, 0.30 and 0.34 cm2 for GMLs at baseline, 2-year and 4-year follow-up, respectively. Mean volumes of lesions for the control group were 4.83, 6.22 and 6.45 cm2 for WMLs and 0.17, 0.25 and 0.23 cm2 for GMLs at baseline, 2-year and 4-year follow-up, respectively. Cross-sectional between-group mean lesion volumes were significantly different for each measure. However, the pattern of WML and GML volume changes over time was not significantly different between groups. Treatment outcome was associated with changes in total and white matter lesion volume over time.

CONCLUSIONS

Lesion volume progression is associated with aging and the pathological condition of late-life depression. The mechanisms that produce these progressive lesion changes remain unclear. Treatments aimed at arresting lesion progression may play a role in the management of late-life depression.

Interrater reliability of measurements of comorbid illness should be reported

OBJECTIVE

Comorbidity indices are commonly used to stratify patients to control for treatment selection bias. The objectives here were to review the reporting of interrater reliability when studies use comorbidity indices in clinical research publications and to report the interrater reliability of four common indices in a particular research setting.

STUDY DESIGN AND SETTING

Four trained abstractors reviewed the same 40 charts of patients with squamous cell carcinoma of the head and neck from a regional cancer center. Scores for the Charlson Index, the Index of Co-existent Disease, the Cumulative Illness Rating Scale, and the Kaplan-Feinstein Classification were calculated, and the intraclass correlation coefficient was used to assess interrater reliability.

RESULTS

The details on the training of abstractors and the results of interrater reliability tests are not commonly reported. In our study setting, the Charlson Index had excellent reliability and the others had acceptable reliability.

CONCLUSION

If the quality of a study using an index or scale is to be assessed, the reliability and interrater reliability of the score assignment process should be reported.

Adjuvant chemotherapy in the elderly: whom to treat, what regimen?

As the elderly population continues to grow, adjuvant chemotherapy treatment in the elderly is becoming an increasingly important issue for the practicing oncologist. Decisions regarding adjuvant treatment involve a careful assessment of the risk for recurrent disease and side effects from treatment, balancing these risks against the beneficial effects of treatment. In this review, we discuss methods for assessing the elderly patient in terms of life expectancy, comorbid disease, and functional capacity. This assessment can then be used to help identify appropriate candidates for adjuvant chemotherapy. Tools for estimating the risk for relapse and mortality and the reduction in these risks with various forms of treatment are useful for clarifying treatment options. Elderly patients have been underrepresented in clinical trials, and patients are often given less intense and possibly inferior standard treatment as a function of age. Ongoing clinical trials targeting the elderly patient may help answer questions about the relative risks and benefits of adjuvant treatment in this age group. Recent data show that most fit elderly patients derive a benefit from standard adjuvant chemotherapy regimens that is equal to that of younger patients.

Quality of care for depressed elders in post-acute care: variations in needs met through services

This paper addresses quality of post-acute care for older adults going home after hospitalization for depression. Quality was conceptualized and assessed in terms of services received for four domains of need: psychiatric, medical, functional, and psychosocial. At discharge, needs for care was assessed using medical records, standardized instruments, and patient interviews; quality of care was assessed by whether or not needs were met by services through the first 6 weeks of post-acute care. Quality of care varied across type of need: psychiatric needs were most likely, and psychosocial needs were least likely, to be met. Urban elders received better psychiatric care than did rural elders. Elders in worse physical health received better medical and psychosocial care, but poorer psychiatric care. Elders with psychoses and living with others had better care for functional dependencies. The competing demands perspective suggests that medical illness may take priority over psychiatric care.

Cognitive function in late life depression: relationships to depression severity, cerebrovascular risk factors and processing speed

BACKGROUND

A number of studies have examined clinical factors linked to worse neuropsychological performance in late life depression (LLD). To understand the influence of LLD on cognition, it is important to determine if deficits in a number of cognitive domains are relatively independent, or mediated by depression- related deficits in a basic domain such as processing speed.

METHODS

Patients who met DSM-IV criteria for major depression (n = 155) were administered a comprehensive neuropsychological battery of tasks grouped into episodic memory, language, working memory, executive function, and processing speed domains. Multiple regression analyses were conducted to determine contributions of predictor variables to cognitive domains.

RESULTS

Age, depression severity, education, race and vascular risk factors all made significant and independent contributions to one or more domains of cognitive function, with all five making independent contributions to processing speed. Age of onset made no independent contribution, after accounting for age and vascular risk factors. Of the five cognitive domains investigated, changes in processing speed were found to most fully mediate the influence of predictor variables on all other cognitive domains.

CONCLUSIONS

While slowed processing speed appears to be the most core cognitive deficit in LLD, it was closely followed by executive function as a core cognitive deficit. Future research is needed to help clarify mechanisms leading to LLD- related changes in processing speed, including the potential role of white matter abnormalities.

Post-acute dispositions of older adults hospitalized for depression

This study addressed factors associated with six-month post-acute dispositions (continuous community stay, medical hospitalization, psychiatric rehospitalization, nursing home placement, death) for older adults hospitalized for depression and discharged to the community. The sample included 199 older adults; and data were collected via medical records, interviews with discharge planners, patients, and family members. Over half of the sample remained in the community throughout the observation period; 23% experienced psychiatric re-admission and 10% entered a nursing home. Several factors associated with nursing home placement were identified: less improvement in depression during the hospitalization, lower Global Assessment of Functioning (GAF) scores at discharge; and less mental health service use in the post-acute period. Those at higher risk of psychiatric re-admission had more previous psychiatric hospitalizations and were marginally more likely to be married and have lower Brief Psychiatric Rating Scale (BPRS) scores at discharge. Differentiating those at risk for nursing home placement may be easier than differentiating those at risk of psychiatric readmission.

Approach to the complications of treatment for acute leukemia in the elderly

Acute leukemia is common in the elderly and, due to the aging population and poorer prognosis, represents a major challenge. Elderly acute leukemia patients have been arbitrarily defined as >or=55 to 65 years of age and are underrepresented in clinical trials. There are physiologic differences between elderly and non-elderly patients. A comprehensive understanding of these differences allows the development of a systematic approach to assessing the risks for treatment-related complications. Use of a comprehensive geriatric assessment (CGA), initially developed and validated in the general geriatric population, may allow more accurate assessment of the likelihood of chemotherapy-induced complications and allow for proactive risk minimization. Once complications to therapy develop, aggressive treatment is essential. Treatment related to common complications that arise from therapy will be reviewed. Further research directed at this population is required.

Age Is Independent of Comorbidity Influencing Patient Selection for Combined Modality Therapy for Treatment of Stage III Nonsmall Cell Lung Cancer (NSCLC)

OBJECTIVES

To determine the influence of age and comorbidity in patient selection for treatment of stage III NSCLC with combined modality therapy (CMT).

METHODS

There were 102 patients with a Karnofsky Performance Score greater than or equal to 70, and clinical stage III NSCLC analyzed retrospectively for comorbidity. All patients received radiotherapy, and 57 (56%) received CMT with sequential and/or concurrent chemotherapy. Comorbidity was rated retrospectively using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). The effect of an extremely severe comorbidity score on patient selection and overall survival (OS) was evaluated.

RESULTS

Presence of a grade 4 comorbidity (P = 0.02) and use of radiation only (P < 0.01) were associated with a statistically significant inferior OS on multivariate analysis, whereas age greater than or equal to 70, clinical stage IIIB, >5% weight loss, and radiation dose >63 Gy were not. Patients receiving CMT were significantly younger (P < 0.001), with less comorbidity (P < 0.001), and weight loss (P = 0.003) compared with patients receiving radiotherapy alone. A multivariate analysis revealed that age (P < 0.001), comorbidity (P = 0.007), and weight loss (P = 0.002) were independent factors influencing patient selection for CMT.

CONCLUSIONS

Age effects patient selection for CMT independent of comorbidity and weight loss in patients with stage III NSCLC and good performance status. This might be related to physician's biases regarding tolerability of CMT in the elderly, and might explain under-representation of elderly in clinical trials of lung cancer. Comorbidity assessment should be included in protocols studying locally advanced stage NSCLC and may be useful for stratification.

Factors disturbing treatment for cancer in patients with schizophrenia

Patients with schizophrenia who develop cancer often have a variety of complicated medical and psychiatric problems. Problems associated with receiving a diagnosis of cancer and with understanding or cooperating with medical treatment may develop. Research in managing and treating schizophrenia patients with cancer is scarce. Presented herein is the experience of the authors' consultation-liaison psychiatry service in treating patients with schizophrenia who have cancer, and discussion of the medical management of such cases. Fourteen patients were treated between April 1999 and March 2003 and included patients receiving consultation psychiatric services at Shimane University Hospital as well as patients referred from other psychiatric hospitals. These patients were divided into two groups based on whether they were amenable to cancer treatment or not. The treated group consisted of patients who accepted cancer treatment, and the untreated group consisted of patients who refused or interrupted the cancer treatment. The clinical course, clinical psychiatric symptoms, problems in understanding cancer, cancer treatment course and convalescence were retrospectively assessed. Psychiatric symptoms and state were measured using the Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale (PANSS). The mean of the duration of schizophrenia in these two groups was not significantly different. The mean scores on measures of psychiatric symptoms in each group (treated and untreated) were as follows: BPRS, 45.3+/-15.4 and 64.9+/-9.2 (P<0.05); positive symptoms scores on PANSS, 14.4+/-8.8 and 20.6+/-6.0 (NS); negative symptoms scores on PANSS, 20.6+/-4.7 and 33.6+/-4.4 (P<0.01); and total scores on PANSS, 31.7+/-7.0 and 48.6+/-7.4 (P<0.01). Patients with severe negative symptoms had greater difficulty understanding and cooperating with the cancer treatment. Regarding cancer stage, when cancer was discovered, the disease had already advanced and was no longer amenable to first-line treatment. Regarding notification of the diagnosis, it was rarely possible to give sufficiently early notice to patients in the untreated group. The important role of consultation-liaison psychiatrist in treating cancer patients is suggested. Some steps are proposed for managing schizophrenia patients with cancer who are not able to give informed consent.

A phase I/II trial of weekly docetaxel and gefitinib in elderly patients with stage IIIB/IV non-small cell lung cancer

BACKGROUND

Phase III trials in elderly patients with advanced (stage IIIB/IV) non-small cell lung cancer (NSCLC) reveal treatment with single agent chemotherapy improves survival. The role of double agent therapy in this patient population is an area of investigation.

METHODS

A phase I/II trial was performed in elderly patients (age>or=70 years) with stage IIIB/IV disease and Eastern Cooperative Oncology Group (ECOG) performance status of 0-2. Patients were treated with gefitinib 250 mg daily. Patients received docetaxel on a treatment schedule of days 1, 8, 15 of an every 28 days schedule. The phase I portion of the trial consisted of dose escalation docetaxel from 30 to 36 mg/m2 using a three patient cohort design. The trial design contained continuous monitoring for excessive toxicity with pre-selected toxicity boundaries.

RESULTS

Twenty-six patients were evaluable for efficacy and toxicity analysis. The median age was 75.5 years. The majority of the patients had stage IV disease (85%), ECOG functional status of 0-1 (81%), were male (65%), and current or former smokers (88%). Eleven patients experienced National Cancer Institute Common Toxicity Criteria grades 3-5 non-hematologic toxicity during the first cycle. The toxicity was determined to be unexpected, and the trial was discontinued. Overall response rate (complete+partial responses) was 31%, and the median survival was 6.5 months (95% confidence interval (CI) (3.6-9.0)), and estimated 1-year survival rate was 27% (95% CI (13-55%)).

CONCLUSIONS

The combination of weekly docetaxel and gefitinib had activity; however, unexpected toxicity was observed in the elderly patient population.

The impact of major depression on outcome following mild-to-moderate traumatic brain injury in older adults

BACKGROUND

Major depression is common following traumatic brain injury (TBI), yet no studies to date have explored its relationship to psychosocial outcome in older adults with TBI.

METHODS

A consecutive sample of seventy-seven older patients with mild-to-moderate TBI was assessed for the presence of major depression within 2 months of injury, and followed prospectively for 1 year. Those with major depression were compared with those without on measures of psychosocial outcome, instrumental activities of daily living (IADL).

RESULTS

Patients with major depression (15.6%) reported higher degrees of psychological distress, psychosocial dysfunction, and post-concussive symptoms than those without, and were rated as having poorer IADL performance.

LIMITATIONS

The present study was limited to a clinical population, and there were significant attrition rates.

CONCLUSIONS

Major depression in the first few months after TBI in older adults has persisting adverse effects on outcome, highlighting its significance in this population, and suggesting early attention to treatment.

Changes in the SF-12 among Depressed Elders Six Months after Discharge from an Inpatient Geropsychiatric Unit

Using the SF-12 to measure physical and mental functioning, the authors examine the intra-individual changes in health-related quality of life (HRQOL) 6 months post-discharge for depressed older adults. In addition, they examine three sets of predictors that might influence these changes. The sample of depressed older adults was recruited from an inpatient geropsychiatry unit. Although their physical and mental health scores on the SF-12 were lower than comparable norms, the sample showed an average increase in their mental functioning but a decrease in the physical functioning over the 6 months. Negative life-events were significant predictors of people who reported no change in their mental health functioning and decreases in their physical health functioning. Interestingly, those who experienced positive life events were more likely to report declines and younger participants were more likely to report no change in their physical functioning. The findings indicate that the effects of depression on HRQOL can have enduring effects on a sample of previously hospitalized older adults. The significance of life event changes might signify the importance of taking into account non-traditional areas of medical interventions. Further, the findings indicate the usefulness of the SF-12 quantifying HRQOL outcomes.

Outcome after traumatic brain injury sustained in older adulthood: a one-year longitudinal study

OBJECTIVE

The objective of this study was to explore the effects of traumatic brain injury (TBI) on cognition and functioning in older adults in a one-year longitudinal study.

METHODS

Participants with mild-to-moderate TBI were compared with an age-, gender-, and education-matched healthy comparison group on aspects of cognition. Neuropsychologic tests were administered at one year. Self-reported measures of functioning were completed at baseline, six months, and one year. Informants rated instrumental functioning at one year.

RESULTS

Sixty-nine subjects aged 50 years and over (mean: 67 years; standard deviation: 7.9) and a comparison group of 79 participants were assessed. Patients with TBI had poorer processing speed, verbal memory, language, and executive function; they self-reported more psychologic distress, psychosocial dysfunction, and postconcussive symptoms; and they were rated as more impaired in functioning than the comparison group. TBI of moderate severity accounted for most of the between-group differences.

CONCLUSION

TBI, particularly of moderate severity, led to poorer cognitive and psychosocial functioning one year postinjury among older adults. The clinical significance of this may become more evident with time in this vulnerable population.

Configuration of services used by depressed older adults

As a more comprehensive service use measure, this study identifies service use configurations based on the use of 17 services. Factors associated with service use configurations are examined guided by the Andersen and Network Episode models. Self-report data at admission and at six-month follow-up were collected, along with information from medical charts among 140 older adults hospitalized for major depression. The data document service access and levels of use in three sectors of care (psychiatric, medical, and psychosocial services) and assess need, predisposing, enabling, and social network factors associated with use. Three distinct service use configurations were identified with cluster analysis: (1) home care users; (2) moderate users of outpatient mental health services; and (3) heavy users of all formal services. Rather than psychiatric needs, post-acute service use was related to: (1) concurrent physical conditions; (2) the availability of formal and informal services; and (3) financial stability. No difference in psychiatric outcomes was found by service use configuration. It is important to understand service use patterns as a measure of service use, given the co-occurring medical, psychiatric, and psychosocial conditions of older adults and corresponding needs in multiple sectors of care.

Persistence of neuropsychologic deficits in the remitted state of late-life depression

OBJECTIVE

Cognitive impairment in late-life depression (LLD) is prevalent, disabling, and persists despite the remission of depressive symptoms. This article characterizes neuropsychologic functioning during remission in LLD.

METHODS

The authors examined longitudinal performance on a comprehensive neuropsychologic battery in 56 nondemented subjects age 60 or older who initially presented with an episode of nonpsychotic unipolar major depression and 40 nondemented, age- and education-equated comparison subjects with no history of depression. Subjects were assessed at baseline (in a depressed state) and one year later (when remitted).

RESULTS

After one year, 45% of the LLD subjects were cognitively impaired despite remission of depression. Visuospatial ability, information-processing speed, and delayed memory were most frequently impaired; 94% of the patients who were impaired at baseline remained impaired one year later. Twenty-three percent of the patients who were cognitively normal while depressed developed impairment one year later.

CONCLUSIONS

Most older individuals who are cognitively impaired during a depressive episode remain impaired when their depression remits. In addition, a substantial proportion of older depressed individuals who are cognitively intact when depressed are likely to be impaired one year later, although their depression has remitted.

What is the optimal duration of a short-term antidepressant trial when treating geriatric depression?

BACKGROUND

To determine the optimal duration of an antidepressant trial in elderly patients, the authors examined the probability of eventually responding to treatment based on early improvement.

METHODS

Four hundred seventy-two elderly patients with major depression (nonpsychotic, nonbipolar) were treated under protocolized conditions for up to 12 weeks and assessed weekly with the Hamilton Rating Scale for Depression. The probability of full response after 12 weeks of treatment was calculated in patients who had not fully responded after periods of treatment that lasted for 4 to 10 weeks.

RESULTS

Most of the patients who had shown a partial improvement after 4 weeks of treatment became full responders after 4 or more additional weeks of treatment. By contrast, only a few of those who were nonresponders became full responders even after up to 8 additional weeks of treatment.

CONCLUSIONS

After 4 weeks of treatment, it is possible to reliably identify a subgroup of elderly patients with depression who are more likely to benefit from a change in their treatment than from a few additional weeks of treatment with the same agent.

Quality of life in chronic lymphocytic leukemia: a neglected issue

Improvement in quality of life (QoL), together with overall survival and disease-free survival, is a relevant endpoint for patients affected by chronic lymphocytic leukemia (CLL), a disease still considered as not curable. In addition, the study of the QoL can significantly contribute to investigate particular aspects related to different treatments which generally are not taken into account in clinical trials. A comprehensive approach to CLL should include also in the day-by-day practice the development of an appropriate and friendly interaction between the physician and patients aimed at improving the process of adaptation encompassing either the 'watch and wait' phase or the treatment period. The present review points out the role of QoL in the global patient management and care of CLL patients also in view of changes in the philosophy of treatment we have witnessed nowadays.

Maintenance treatment of major depression in old age

BACKGROUND

Elderly patients with major depression, including those having a first episode, are at high risk for recurrence of depression, disability, and death.

METHODS

We tested the efficacy of maintenance paroxetine and monthly interpersonal psychotherapy in patients 70 years of age or older who had depression (55 percent of whom were having a first episode) in a 2-by-2, randomized, double-blind, placebo-controlled trial. Among patients with a response to treatment with paroxetine and psychotherapy, 116 were randomly assigned to one of four maintenance-treatment programs (either paroxetine or placebo combined with either monthly psychotherapy or clinical-management sessions) for two years or until the recurrence of major depression. Clinical-management sessions, conducted by the same nurses, social workers, and psychologists who provided psychotherapy, involved discussion of symptoms.

RESULTS

Major depression recurred within two years in 35 percent of the patients receiving paroxetine and psychotherapy, 37 percent of those receiving paroxetine and clinical-management sessions, 68 percent of those receiving placebo and psychotherapy, and 58 percent of those receiving placebo and clinical-management sessions (P=0.02). After adjustment for the effect of psychotherapy, the relative risk of recurrence among those receiving placebo was 2.4 times (95 percent confidence interval, 1.4 to 4.2) that among those receiving paroxetine. The number of patients needed to be treated with paroxetine to prevent one recurrence was 4 (95 percent confidence interval, 2.3 to 10.9). Patients with fewer and less severe coexisting medical conditions (such as hypertension or cardiac disease) received greater benefit from paroxetine (P=0.03 for the interaction between treatment with paroxetine and baseline severity of medical illness).

CONCLUSIONS

Patients 70 years of age or older with major depression who had a response to initial treatment with paroxetine and psychotherapy were less likely to have recurrent depression if they received two years of maintenance therapy with paroxetine. Monthly maintenance psychotherapy did not prevent recurrent depression. (ClinicalTrials.gov number, NCT00178100.).

Self-rated global measure of the frequency, intensity, and burden of side effects

No standard side-effect measure currently available can be easily used in clinical practice for patients receiving treatment for depression. The Frequency, Intensity, and Burden of Side Effects Rating (FIBSER) Scale was developed to document these three domains of side effects in patients treated in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) project. This article presents data on the reliability and validity of the FIBSER. The STAR*D prospectively enrolled 4,041 outpatients with nonpsychotic major depressive disorder (MDD) who were seeking medical care (as opposed to symptomatic volunteers recruited via advertisements). The patients were treated with citalopram. Clinical assessments, including the FIBSER, were completed at 2, 4, 6, 9, 12, and, if necessary, 14 weeks after enrollment. The FIBSER was shown to be reliable, with high correlations between observations taken a short time apart, and correlations decreasing as time between observations increased. There were also consistent relationships between items over time. The FIBSER has both face and construct validity. Thus, the FIBSER is a reliable and valid self-report measure of side effects in a population receiving treatment for depression. Although it does not measure the impact of specific side effects, it does measure three domains of impact: frequency, intensity, and burden of the side effects. Its brevity makes it a useful tool for routine clinical practice. These advantages are not available in other side-effect measures.

Parathyroidectomy improves neurocognitive deficits in patients with primary hyperparathyroidism

BACKGROUND

Clinical guidelines for the treatment of primary hyperparathyroidism (pHPT) often suggest parathyroidectomy, but generally fail to consider neurocognitive and psychiatric symptoms because of the relative paucity of evidence.

METHODS

In this prospective study, patients with pHPT (PTX) and benign euthyroid thyroid disease (THY) referred for operation were evaluated pre- and postoperatively with validated psychometric and neurocognitive instruments to determine whether learning, memory, or concentration improved with after parathyroidectomy. Statistical comparisons between groups were performed with univariate analysis and repeated measures of analysis of variance.

RESULTS

Fifty-five subjects, mean age of 54 years, were evaluated preoperatively; 41 returned postoperatively. There were no significant differences between groups by age and gender. PTXs reported more depression symptoms preoperatively (P = .04) that improved postoperatively. There were no differences between the 2 groups on verbal memory and trait anxiety. For PTXs, average preoperative serum calcium concentration (11.3 mg/dL) and serum PTH level (100 pg/mL) normalized postoperatively. Preoperatively PTXs showed greater delays in their spatial learning (P = .03). All subjects learned across the 5 trials, but PTXs were more delayed (P = .03). After operation, PTXs improved and functioned at a level equivalent to the THYs. There was an interaction between trial (neurocognitive testing), visit (pre- vs postoperative), status (PTX vs THY), and change in PTH level (P = .06), suggesting that individuals with greater change in PTH were more likely to improve in their learning efficiency postparathyroidectomy.

CONCLUSIONS

PHPT may be associated with a spatial learning deficit and processing that improves after parathyroidectomy. While longer-term follow-up is necessary, neurocognitive symptoms perhaps should be considered as criteria for parathyroidectomy.

Daytime sleeping, sleep disturbance, and circadian rhythms in the nursing home

OBJECTIVE

This study reports the frequency of abnormal daytime sleeping and identifies factors related to daytime sleeping, nighttime sleep disturbance, and circadian rhythm abnormalities among nursing home residents.

METHODS

The authors conducted secondary analysis of data collected under usual care conditions within a nonpharmacologic sleep intervention trial. All residents from four Los Angeles nursing homes were screened for daytime sleeping (asleep>or=15% of observations, 9:00 am-5:00 pm). Consenting residents with daytime sleeping had two nights of wrist actigraphy to assess nighttime sleep disturbance (asleep<80%, 10:00 pm-6:00 am). Residents with nighttime sleep disturbance completed an additional 72-hour wrist actigraphy recording to assess circadian activity rhythms and light exposure.

RESULTS

Sixty-nine percent of 492 observed residents had daytime sleeping, of whom 60% also had disturbed nighttime sleep. Sleep disturbance and daytime sleeping were rarely documented in medical records. Residents spent one-third of the day in their rooms, typically in bed, and were seldom outdoors or exposed to bright light. More time in bed and less social activity were significant predictors of daytime sleepiness. Ninety-seven percent of residents assessed had abnormal circadian rhythms. More daytime sleeping and less nighttime sleep were associated with weaker circadian activity rhythms. Later circadian rhythm acrophase (peak) was associated with more bright light exposure.

CONCLUSION

Daytime sleepiness, nighttime sleep disturbance, and abnormal circadian rhythms were common in nursing home residents. Modifiable factors (e.g., time in bed) are associated with sleep/wake abnormalities. Mental health specialists should consider the complexity of factors causing sleep problems in nursing home residents.

Interviews or medical records, which type of data yields the best information on elderly people's health status?

BACKGROUND AND AIMS

Self-reported data and/or medical records are often used to assess the prevalence of illness and impairment in epidemiological studies. However, these two data sources do not always provide the same information. The aim was to compare data from interviews and medical records regarding illness, symptoms and impairment in the elderly, and to analyze the agreement between a consensus from both data sources and data from interviews and medical records, respectively.

METHODS

We interviewed 130 persons (age range 67-99) regarding socio-demographic background data and physical and mental health. Medical records were reviewed. Illness burden was rated according to the Cumulative Illness Rating Scale for Geriatrics, and was rated in three ways based on: (1) interview data; (2) medical records; (3) information from both interviews and medical records considered to be consensus. Agreement was measured by the Kappa coefficient and the Svensson Paired Rank Measurement. A permutation test tested whether the ratings from interviews and medical records had the same agreement when compared with consensus.

RESULTS

Statistically significant differences in agreement were found between interview versus consensus and medical records versus consensus for the vascular system (medical records best), eyes/ears/nose/throat/larynx and musculoskeletal/integument (interview best). Medical records gave better in formation concerning specific diseases and diagnoses, whereas interview data provided a better measure of illness, functional impairment and health in a broader sense.

CONCLUSIONS

Both medical records and interviews yield good information of elderly people's health status, but they focus on different aspects of health.

Methylphenidate-enhanced antidepressant response to citalopram in the elderly: a double-blind, placebo-controlled pilot trial

OBJECTIVE

The authors evaluated the potential of methylphenidate to accelerate and enhance antidepressant response to citalopram in elderly depressed patients.

METHODS

Sixteen outpatients with major depression were treated in a 10-week double-blind trial. Response was defined as a score on the Hamilton Depression Rating Scale (24-item) of less than 10.

RESULTS

An accelerated response was observed by week 3 in five subjects receiving citalopram (CIT)+methylphenidate (MPH) and in none of those receiving CIT+placebo (PBO). Subjects receiving citalopram and methylphenidate showed a significant improvement in depressive symptoms compared with those on citalopram and placebo.

CONCLUSION

Combined treatment with citalopram and methylphenidate appears to be a viable strategy for accelerating and enhancing antidepressant response in elderly depressed patients limited by tolerability and safety.

Validation of a brief screening instrument for substance abuse and mental illness in HIV-positive patients

BACKGROUND

Substance abuse (SA) and mental illness (MI) commonly co-occur with HIV infection in the United States and have important implications for clinical management of HIV/AIDS. Yet SA/MI often go untreated due in part to a lack of practical, validated screening tools.

SETTING

HIV clinic in academic medical center.

METHODS

The 16-item SA/MI Symptoms Screener (SAMISS) targets SA/MI in HIV-positive patients. Consecutive consenting HIV-positive patients completed the SAMISS and then a reference standard diagnostic tool, SCID, the Structured Clinical Interview for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition).

RESULTS

Twenty percent of participants (29/148) had an SA diagnosis and 41% (59/143) had an MI diagnosis in the past year on the SCID; 48% (68/143) had 1 or both. Thirty-seven percent (55/148) screened positive for SA and 69% (99/143) screened positive for MI on the SAMISS. The SAMISS had 86% (95% CI: 68%-96%) sensitivity and 75% (66%-82%) specificity for SA and 95% (86%-99%) sensitivity and 49% (38%-60%) specificity for MI. Patients with SA were likely to show up as false positives for MI and vice versa.

CONCLUSION

The SAMISS functioned well as a first-line screening tool for SA/MI in this HIV clinic population. It missed few cases and was easily incorporated into a busy clinical setting. Persons screening positive require a more rigorous confirmatory psychiatric evaluation.

Clinical characteristics of depressed patients with comorbid diabetes mellitus

Both diabetes and depression are highly prevalent. Patients with diabetes experience higher rates of depression compared to the general population. When present, depression is associated with an increase in the morbidity and mortality of diabetes, suggesting the importance of treatment in this population. The objective of the present study was to characterize depressive characteristics in depressed patients with and without comorbid diabetes. Seventeen patients with type 1 or type 2 diabetes were drawn from outpatient clinical trials. Depressed patients without diabetes were identified from the same studies. Unpaired t-tests and multiple chi-square analyses were used to compare demographic and clinical characteristics between the samples. Diabetic patients in our sample were more depressed and reported lower levels of somatic well-being and contentment compared to non-diabetic patients. The samples did not differ significantly along other dimensions of depression, including course of illness, response to previous treatments and comorbid conditions. These findings suggest that depressed diabetic patients are more similar than not to non-diabetic depressed patients, although important differences exist.

Correlation between anemia and functional/cognitive capacity in elderly lung cancer patients treated with chemotherapy

BACKGROUND

Elderly cancer patients are often excluded from clinical trials and no data are available on the impact of chemotherapy-related anemia on their functional status and cognitive functions. This observational study investigates the association between hemoglobin (Hb) level and comprehensive geriatric assessment (CGA) variables (MMSE, ADL/IADL, GDS, CIRS and VAS).

PATIENTS AND METHODS

We enrolled 42 consecutive lung cancer elderly patients undergoing chemotherapy that were evaluated at baseline and after each CT cycle at least until cycle 2. Hb association with CGA indexes was expressed using Spearman's non-parametric coefficient r.

RESULTS

Higher Hb values were significantly associated with more favourable values of all indexes measuring mental and functional capacity, depression and comorbidities. For all indexes except IADL, improvements from baseline were significantly related with concomitant Hb increases. In 14 patients given erythropoietin during the first two cycles, mean Hb increased from 9.2 to 10.8 g/dl, and the mean values of all CGA indexes were improved. On the contrary, in 18 patients not given erythropoietin, Hb varied from 13.0 to 11.2 g/dl and a parallel worsening in all CGA indexes was observed.

CONCLUSIONS

Chemotherapy-related anemia is associated with impairment of functional status and cognitive functions. In elderly cancer patients anemia correction or maintenance could be useful to preserve functional independency and protect from mental decay. However, the study results need to be confirmed on a larger series of patients within a controlled clinical trial.

Predictive validity of five comorbidity indices in prostate carcinoma patients treated with curative intent

BACKGROUND

Comorbidity is important to consider in clinical research on curative prostate carcinoma because of the role of competing risks. Five chart-based comorbidity indices were assessed for their ability to predict survival.

METHODS

This was a case-cohort study of prostate carcinoma patient cohort treated with curative intent in Toronto and Southeast Cancer Care Ontario regions between 1990 and 1996; the subcohort was drawn from these men, whereas cases were cohort members who died from causes other than prostate carcinoma. Comorbidity data were obtained from medical charts (269 subjects). Vital status, age, area of residence, and socioeconomic status information were available. Predictive validity was quantified by the percent variance explained (PVE) over and above age using proportional hazards modeling.

RESULTS

The Chronic Disease Score (CDS) (PVE = 11.3%; 95% confidence interval [95% CI], 3.5-22.8%), Index of Coexistent Disease (ICED) (PVE = 9.0%; 95% CI, 2.9-17.9%), Cumulative Illness Rating Scale (CIRS) (PVE = 7.2%; 95% CI, 1.4-17.1%), Kaplan-Feinstein Index (PVE = 4.9%; 95% CI, 0.6-12.8%), and Charlson Index (PVE = 3.8%; 95% CI, 0.3-10.9%) each explained some outcome variability beyond age. PVE differences among indices were not statistically significant. A comorbidity identified at the time of cancer diagnosis was the cause of death in 59.2% of cases (75% for cardiac or vascular causes).

CONCLUSIONS

The better-performing, more comprehensive indices (CDS, ICED, and CIRS) would be useful in measuring and controlling for comorbidity in this setting. The CDS was easiest to apply and explained the most outcome variability.

Comparative assessment of three different indices of multimorbidity for studies on health-related quality of life

BACKGROUND

Measures of multimorbidity are often applied to source data, populations or outcomes outside the scope of their original developmental work. As the development of a multimorbidity measure is influenced by the population and outcome used, these influences should be taken into account when selecting a multimorbidity index. The aim of this study was to compare the strength of the association of health-related quality of life (HRQOL) with three multimorbidity indices: the Cumulative Illness Rating Scale (CIRS), the Charlson index (Charlson) and the Functional Comorbidity Index (FCI). The first two indices were not developed in light of HRQOL.

METHODS

We used data on chronic diseases and on the SF-36 questionnaire assessing HRQOL of 238 adult primary care patients who participated in a previous study. We extracted all the diagnoses for every patient from chart review to score the CIRS, the FCI and the Charlson. Data for potential confounders (age, sex, self-perceived economic status and self-perceived social support) were also collected. We calculated the Pearson correlation coefficients (r) of the SF-36 scores with the three measures of multimorbidity, as well as the coefficient of determination, R2, while controlling for confounders.

RESULTS

The r values for the CIRS (range: -0.55 to -0.18) were always higher than those for the FCI (-0.47 to -0.10) and Charlson (-0.31 to -0.04) indices. The CIRS explained the highest percent of variation in all scores of the SF-36, except for the Mental Component Summary Score where the variation was not significant. Variations explained by the FCI were significant in all scores of SF-36 measuring physical health and in two scales evaluating mental health. Variations explained by the Charlson were significant in only three scores measuring physical health.

CONCLUSION

The CIRS is a better choice as a measure of multimorbidity than the FCI and the Charlson when HRQOL is the outcome of interest. However, the FCI may provide a good option to evaluate the physical aspect of HRQOL for the ease in its administration and scoring. The Charlson index may not be recommended as a measure of multimorbidity in studies related to either physical or mental aspects of HRQOL.

Prognostic factors in non-small cell lung cancer surgery

AIMS

Complete surgical resection of primary tumours remains the treatment with the greatest likelihood for survival in early-stage non-small cell lung cancer (NSCLC). Although TNM stage is the most important prognostic parameter in NSCLC, additional parameters are required to explain the large variability in postoperative outcome. The present review aims at providing an overview of the currently known prognostic markers for postoperative outcome.

METHODS

We performed an electronic literature search on the MEDLINE database to identify relevant studies describing the risk factors in NSCLC surgery. The references reported in all the identified studies were used for completion of the literature search.

RESULTS

Poor pulmonary function, cardiovascular disease, male gender, advanced age, TNM stage, non-squamous cell histology, pneumonectomy, low hospital volume and little experience of the surgeon were identified as risk factors for postoperative outcome. However, with the exception of TNM stage and extent of resection, the literature demonstrates conflicting results on the prognostic power of most factors. The role of molecular biological factors, neoadjuvant treatment and adjuvant treatment is not well investigated yet.

CONCLUSIONS

The advantage of knowing about the existence of comorbidity and prognostic risk factors may provide the clinician with the ability to identify poor prognostic patients and establish the most appropriate treatment strategy. The assessment of prognostic factors remains an area of active investigation and a promising field of research in optimising therapy of NSCLC patients.

A new simplified comorbidity score as a prognostic factor in non-small-cell lung cancer patients: description and comparison with the Charlson's index

Treatment of non-small-cell lung cancer (NSCLC) might take into account comorbidities as an important variable. The aim of this study was to generate a new simplified comorbidity score (SCS) and to determine whether or not it improves the possibility of predicting prognosis of NSCLC patients. A two-step methodology was used. Step 1: An SCS was developed and its prognostic value was compared with classical prognostic determinants in the outcome of 735 previously untreated NSCLC patients. Step 2: the SCS reliability as a prognostic determinant was tested in a different population of 136 prospectively accrued NSCLC patients with a formal comparison between SCS and the classical Charlson comorbidity index (CCI). Prognosis was analysed using both univariate and multivariate (Cox model) statistics. The SCS summarised the following variables: tobacco consumption, diabetes mellitus and renal insufficiency (respective weightings 7, 5 and 4), respiratory, neoplastic and cardiovascular comorbidities and alcoholism (weighting=1 for each item). In step 1, aside from classical variables such as age, stage of the disease and performance status, SCS was a statistically significant prognostic variable in univariate analyses. In the Cox model weight loss, stage grouping, performance status and SCS were independent determinants of a poor outcome. There was a trend towards statistical significance for age (P=0.08) and leucocytes count (P=0.06). In Step 2, both SCS and well-known prognostic variables were found as significant determinants in univariate analyses. There was a trend towards a negative prognostic effect for CCI. In multivariate analysis, stage grouping, performance status, histology, leucocytes, lymphocytes, lactate dehydrogenase, CYFRA 21-1 and SCS were independent determinants of a poor prognosis. CCI was removed from the Cox model. In conclusion, the SCS, constructed as an independent prognostic factor in a large NSCLC patient population, is validated in another prospective population and appears more informative than the CCI in predicting NSCLC patient outcome.

Elderly patients with advanced colorectal cancer: which therapy is the safest?

Patients > 65 years of age are the fastest growing segment of the cancer population. It is estimated that within 20 years, > 75% of cases and 85% of deaths from colorectal cancer (CRC) will be in this setting. Concerns about cancer treatment in the elderly relate to comorbidities, which increase proportionally with age, physiological changes associated with ageing that may influence drug metabolism and toxicity, and diminishing life expectancy, which particularly impacts decisions surrounding the benefits of adjuvant therapies. Over the last 10 years, significant improvements in the treatment of advanced CRC with combination therapy have been made. The randomised trials that have defined these improvements did not exclude elderly patients; however, the median age of patients in these trials has generally been approximately 60 years. Thus, it appears that some degree of selection is involved with younger and presumably fitter patients being the subjects in most of the pivotal trials. The availability of new molecularly targeted agents and newly improved existing agents has expanded the range of treatment options available. This variety gives greater flexibility in dealing with different subsets of patients, such as the elderly. However, some fit elderly patients seem to tolerate combination therapy reasonably well, whereas studies on unfit elderly subjects are needed.

Influence of age, gender, health status, and depression on quantitative EEG

Quantitative electroencephalography (QEEG) has shown increasing utility in assessing brain function in clinical research studies of depression. QEEG findings may be influenced by a variety of factors other than the presence of depression, including age, gender, depression severity, and physical health status. Many of these factors have not been systematically evaluated. We therefore examined QEEG measures in 104 subjects with depression and normal controls to determine the influence of these factors. We examined QEEG power as well as cordance, a QEEG measure that has a stronger association with cerebral perfusion than conventional QEEG measures. Prefrontal cordance in the theta band has been associated with the pathophysiology of depression and response to treatment. We found that prefrontal cordance and relative power in the theta band were unaffected by age, gender, severity of depression, and health status, while prefrontal absolute power was higher in women than men. All of these measures were different from global measures of absolute and relative power, which were influenced by age, gender, and health status. These findings suggest that prefrontal cordance in depressed patients is not significantly affected by factors of age, gender, severity of depression, or physical illness. Global measures of power, and to a lesser extent prefrontal absolute power, must be interpreted with regard to confounding factors of age, gender, physical illness, and severity of depression.