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

Assessing comorbidity in patients with Parkinson's disease

The aim of this study was to assess the accuracy of an interview-based assessment of comorbidity, in patients with Parkinson's disease (PD). The Cumulative Illness Rating Scale-Geriatric (CIRS-G) was completed (1) in an interview with 31 PD patients and their caregivers, and (2) by reviewing the patient's medical charts from their general practitioners. Based on the interview, all patients had some comorbidity, 84% had one or more moderate comorbid diseases. The most frequently affected organ systems were "lower gastrointestinal" and "genitourinary". The mean +/- SD total score of the interview-based (chart-based) CIRS-G was 6.9 +/- 3.8 (7.6 +/- 3.5) with a mean of 4.3 +/- 1.9 (5.0 +/- 1.9) affected organ systems and a mean of 2.1 +/- 1.7 (2.3 +/- 1.6) organ systems with at least moderate comorbidity per patient. The agreement (intraclass correlation coefficients) between the interview-based and chart-based assessments for the six summary scores ranged from 0.69 to 0.81. The agreement for the 14 organ systems ranged from 0.13 to 1.00 (weighted kappa); 12 had a K(w) above 0.40 (moderate agreement). The comorbidity summary scores had a moderate correlation with age and disability. The interview-based assessment of the CIRS-G is easy to apply and is an accurate method to assess comorbidity in patients with PD.

Late onset dysthymic disorder and major depression differ from early onset dysthymic disorder and major depression in elderly outpatients

BACKGROUND

Age of onset may affect clinical features and prognosis in elderly patients with major depression (MDD), but there is a lack of such data in elderly patients with dysthymic disorder (DD) and systematic comparisons of late onset MDD and DD have not been conducted.

METHODS

In a Late Life Depression Clinic, patients > or = 60 years old who met DSM-III-R or DSM-IV criteria for MDD or DD were studied. The 24-item Hamilton Rating Scale for Depression (HRSD) and SCID-P were completed, family history was obtained, and medical illnesses were assessed.

RESULTS

In the total sample (n=370; 211 MDD and 159 DD), compared to early onset patients, late onset (onset > or =60 years) patients had a higher rate of cardiovascular disease (chi(2)=4.12, df=1, P<0.05), lower rate of anxiety disorder (chi(2)=4.19, df=1, P<0.05), and a lower rate of family history of affective disorder (chi(2)=9.37, df=1, P<0.002). Late onset DD patients were more likely to have cardiovascular disease than early onset DD patients (chi(2)=5.63, df=1, P<0.02), but the rate of cardiovascular disease did not differ between late and early onset MDD patients (chi(2)=0.35, df=1, P<0.6). Late onset MDD patients were less likely to have a family history of affective disorder than early onset MDD patients (chi(2)=10.71, df=1, P<0.001). Prevalence of anxiety disorders did not differ between the early and late onset MDD patients (chi(2)=0.07, df=1, P<0.79), but was more common in the early onset DD compared to the late onset DD patients (17.98% versus 4.29%, chi(2)=6.98, df=1, P<0.01). Late onset DD did not differ from late onset MDD in the rates of cardiovascular disease, anxiety disorders, and family history of affective disorder. Excluding patients with double depression (n=32) did not alter the cardiovascular or family history findings, but the difference in anxiety disorders between early and late onset DD patients was no longer significant.

LIMITATIONS

Academic clinic sample results may not generalize to community populations.

CONCLUSIONS

In the elderly, late-onset DD is typically different from early onset DD. Cerebrovascular disease appears to play a role in the etiology of late onset DD. The similarities between late onset DD and late onset MDD suggest a single condition along a continuum.

Clinical characteristics of magnetic resonance imaging-defined subcortical ischemic depression

BACKGROUND

There is a substantial body of research supporting the vascular depression hypothesis of late-life depression. To update this hypothesis so it incorporates recent research, we propose that the term subcortical ischemic vascular depression may be a more accurate representation of the disease process. We sought to investigate this diagnosis as a construct by examining differences between depressed subjects with and without magnetic resonance imaging defined subcortical ischemic vascular depression.

METHODS

This case-control study examined 139 depressed elderly subjects. Demographic data, psychiatric, medical, and family history, depressive symptomatology, and functional impairment were compared between groups dichotomized based on neuroimaging findings.

RESULTS

Seventy-five (54%) of the subjects met neuroimaging criteria for subcortical ischemic vascular depression. Age was most strongly associated with increased prevalence of subcortical ischemic vascular depression. Lassitude and a history of hypertension were also positively associated with the diagnosis; a family history of mental illness and loss of libido were negatively associated with the diagnosis.

CONCLUSIONS

These data support that subcortical ischemic vascular depression may be a specific syndrome from other types of late-life depression. Further research is needed to further characterize this disorder, particularly in regards to cognitive function and treatment implications.

Are nursing homes appropriate for older adults with severe mental illness? Conflicting consumer and clinician views and implications for the Olmstead decision

OBJECTIVES

In response to the recent Olmstead decision, to compare consumer and clinician perspectives on the appropriateness of nursing home settings for older adults with severe mental illness (SMI) in relation to clinical characteristics and care needs.

DESIGN

Cross-sectional, descriptive, correlational study.

SETTING

Ten community mental health centers and two state-funded nursing homes specializing in long-term care for older persons with SMI.

PARTICIPANTS

Consumers of mental health services in the community (n=115) and in nursing homes (n=106), aged 60 and older, with SMI. Sixty-four clinicians (51% registered nurses, 29% masters-level clinicians, and 20% certified social workers) conducted ratings.

MEASUREMENTS

Consumers and their clinicians were independently asked to determine the most appropriate care setting for each consumer based on care needs from three alternatives: nursing home, congregate (group) living setting, or individual apartment/home. Clinical characteristics of participants with SMI were rated using the Mini-Mental State Examination, Brief Psychiatric Rating Scale, Specific Level of Function Scale, Cumulative Illness Rating Scale for Geriatrics, a modified memory and orientation subscale from the Clinical Dementia Rating Scale, and an item from the Minimum Data Set related to reasoning.

RESULTS

Of nursing home residents with SMI who did not have severe cognitive impairment, 40% (n=42) and 51% (n=54) were considered by consumers or by their clinician, respectively, to be more appropriate for a community-based setting, but there was a low level of agreement (only 27.6%; no better than chance) between consumers and clinicians on which nursing home residents were most appropriate for living in the community. Determinations by clinicians were associated with clinical need (diagnosis and less-severe behavioral problems), whereas there was no association between clinical needs and level of care determinations by consumers. Finally, clinicians considered a group home necessary for 93.7% of nursing home residents judged to be more appropriate for a community-based setting, whereas 90.5% of consumers stated that an apartment or individual home was indicated.

CONCLUSION

State implementation of the Olmstead decision will need to consider major differences in perspectives between clinicians and consumers on the most appropriate long-term care setting for older persons with SMI.

Effectiveness of electroconvulsive therapy in community settings

BACKGROUND

Clinical trials indicate that electroconvulsive therapy (ECT) is the most effective treatment for major depression, but its effectiveness in community settings has not been examined.

METHODS

In a prospective, naturalistic study involving 347 patients at seven hospitals, clinical outcomes immediately after ECT and over a 24-week follow-up period were examined in relation to patient characteristics and treatment variables.

RESULTS

The sites differed markedly in patient features and ECT administration but did not differ in clinical outcomes. In contrast to the 70%-90% remission rates expected with ECT, remission rates, depending on criteria, were 30.3%-46.7%. Longer episode duration, comorbid personality disorder, and schizoaffective disorder were associated with poorer outcome. Among remitters, the relapse rate during follow-up was 64.3%. Relapse was more frequent in patients with psychotic depression or comorbid Axis I or Axis II disorders. Only 23.4% of ECT nonremitters had sustained remission during follow-up.

CONCLUSIONS

The remission rate with ECT in community settings is substantially less than that in clinical trials. Providers frequently end the ECT course with the view that patients have benefited fully, yet formal assessment shows significant residual symptoms. Patients who do not remit with ECT have a poor prognosis; this underscores the need to achieve maximal improvement with this modality.

Medical assessment in drug addicts: reliability and validity of the Cumulative Illness Rating Scale (Substance Abuse version)

OBJECTIVE

To adapt the Cumulative Illness Rating Scale for its use in substance abuse patients (CIRS-SA) and to assess the reliability, internal consistency, and validity of the instrument.

METHOD

One-hundred outpatients of both sexes, 62 men and 38 women, with a mean (SD) age of 32.4 (7.9) years (range 19-57), all of them fulfilling the DSM-IV criteria for any substance abuse disorder. Internal consistency was calculated with Cronbach's alpha coefficient. Test-retest and interrater reliability was assessed with the intraclass correlation coefficient and Wilcoxon z. Validity of the scale was assessed with Kendall's tau correlation coefficient.

RESULTS

The final CIRS-SA version had a total of 13 items. Cronbach's alpha coefficient was 0.57. All intraclass correlation coefficients were above 0.7, and some items showed exact coincidence. The stability of the CIRS-SA scale in a 1-month test re-test reassessment was demonstrated. The CIRS-SA score showed a significant correlation with all consultant scores.

CONCLUSION

CIRS-SA is a reliable and valid instrument to assess and to determine systematically the physical condition of substance abusers in whom infections, particularly by the HIV, are highly prevalent.

Clinical characteristics of flexed posture in elderly women

OBJECTIVES

To investigate the relationships between the severity of flexed posture (FP), skeletal fragility, and functional status level in elderly women.

DESIGN

Cross-sectional study.

SETTING

Geriatric rehabilitation research hospital.

PARTICIPANTS

Sixty elderly women (aged 70-93) with FP referred to a geriatric rehabilitation department for chronic back pain without apparent comorbid conditions.

MEASUREMENTS

Multidimensional clinical assessment included the severity of FP (standing occiput-to-wall distance) demographic (age) and anthropometric (height, weight) data, clinical profile (number of falls, pain assessment, Mini-Mental State Examination, Comorbidity Severity Index, Geriatric Depression Scale, Multidimensional Fatigue Inventory), measures of skeletal fragility (number of vertebral fractures by spine radiograph, bone mineral density (BMD), and T-score of lumbar spine and proximal femur), muscular impairment assessment (muscle strength and length), motor performance (Short Physical Performance Battery, Performance Oriented Mobility Assessment, instrumented gait analysis), and evaluation of disability (Barthel Index, Nottingham Extended Activities of Daily Living Index).

RESULTS

The severity of FP was classified as mild in 11, moderate in 28, and severe in 21 patients. Although there were no differences between FP groups on the skeletal fragility measurements, the moderate and severe FP groups were significantly different from the mild FP group for greater pain at the level of the cervical and lumbar spine. The severe FP group was also significantly different from the mild but not the moderate FP group in the following categories: clinical profile (greater depression, reduced motivation), muscle impairment (weaker spine extensor, ankle plantarflexor, and dorsiflexor muscles; shorter pectoralis and hip flexor muscles), the motor function performance-based tests (lower scores in the balance and gait subsets of the Performance Oriented Mobility Assessment), the instrumented gait analysis (slower and wider base of support), and disability (lower score on the Nottingham Extended Activities of Daily Living Index). The total number of vertebral fractures was not associated with differences in severity of FP, demographic and anthropometric characteristics, clinical profile, muscular function, performance-based and instrumental measures of motor function, and disability, but it was associated with reduced proximal femur and lumbar spine BMD.

CONCLUSION

The severity of FP in elderly female patients (without apparent comorbid conditions) is related to the severity of vertebral pain, emotional status, muscular impairments, and motor function but not to osteoporosis, and FP has a measurable effect on disability. In contrast, the presence of vertebral fractures in patients with FP is associated with lower BMD but not patients' clinical and functional status. Therefore, FP, back pain, and mobility problems can occur without osteoporosis. Older women with FP and vertebral pain may be candidates for rehabilitation interventions that address muscular impairments, posture, and behavior modification. Randomized controlled trials are needed to support these conclusions.

Concordance of four methods of disability assessment using performance in the home as the criterion method

OBJECTIVE

To determine the concordance of 4 methods of disability assessment with the criterion method. Performance testing in the home was selected as the criterion.

METHODS

The task performance of 57 community-dwelling older women (>/=70 years) with knee osteoarthritis was examined through self report, proxy report, clinical judgment based on impairment measures, performance testing in an occupational therapy clinic, and performance testing in participants' homes. The 26 tasks represented 4 domains of daily living activities: 5 functional mobility, 3 personal care, 14 cognitively oriented instrumental activities of daily living (IADL), and 4 physically oriented IADL.

RESULTS

In general, self reports and proxy reports had the highest concordance with in-home performance test results. Nonetheless, even for these methods, depending on task domain, the rate of discordance ranged from 31% to 54%, being least in personal care and greatest in the physically oriented IADL.

CONCLUSION

Disability estimates based on self reports, proxy reports, clinical judgments, and hospital performance-based assessments are not interchangeable with in-home task performance.

Depression in later-life Puerto Rican primary care patients: the role of illness, stress, social integration, and religiosity

BACKGROUND

Older Puerto Ricans belong to two rapidly growing demographic groups known to have high rates of depression: the aging and Hispanic populations. Studies of depression in Puerto Ricans have primarily focused on the impact of demographic factors and health. This study expands previous research, examining the relationships between depression and social stressors, social support, and religiosity, for Puerto Rican primary care patients aged 50 and older.

PATIENTS

Participants included 303 Puerto Ricans from six primary care clinics in a northeastern city.

METHODS

Patients completed in-person interview in Spanish. The Composite International Diagnostic Interview indicated depressive disorders meeting DSM-IV criteria. Bivariate and multivariate relationships between depression and demographics, health, social stress and support, and religiosity were explored.

RESULTS

One fifth of participants met DSM-IV criteria for major depression or dysthymia. Participants with the lowest income, more recent migration, and poor subjective health were significantly more likely to be depressed. In addition, rates of depression increased steeply for patients caring for grandchildren and those with personal or family legal problems. Seeing few relatives each month and needing more instrumental, emotional, or financial support were also related to higher rates of depression. Unexpectedly, low objective illness severity correlated with increased depression, whereas religiosity and religious participation had no relationship to depression.

CONCLUSIONS

The findings presented here indicate the potential for social stressors and inadequate supports to substantially increase the risk of depression in older Puerto Ricans in primary care settings. Further studies should explore incorporating these social risk factors into improved prevention, clinical detection, and culturally sensitive treatment of older depressed Puerto Ricans.

Predictors of suicide in the old elderly

BACKGROUND

Seniors aged 75 and above have the highest suicide rates of all age groups in most industrialized countries. However, research concerning risk factors for suicide in the old elderly is sparse.

OBJECTIVE

The purpose was to determine predictors for suicide among the old elderly (75+). Data concerning the young elderly (65-74 years) are shown for comparison.

METHODS

85 consecutive cases of suicide that occurred in western Sweden and 153 control persons with the same sex, birth year, and zip code as the suicide cases were randomly selected from the tax register. The old elderly group included 38 cases and 71 controls; the young elderly group included 47 cases and 82 controls. Data concerning the suicide cases were collected through interviews with close informants; controls were interviewed in person. The interview included questions on past-year life events and mental and physical health. Medical records were reviewed for cases and controls. The Cumulative Illness Rating Scale - Geriatrics was used to rate illness burden.

RESULTS

Family conflict, serious physical illness, loneliness, and both major and minor depressions were associated with suicide in the 75+ group. Economic problems predicted suicide in the younger but not in the older elderly. Old elderly suicide victims with depression (major or minor) were less likely to have received depression treatment than their younger counterparts.

CONCLUSIONS

Better recognition and treatment of both major and minor depression should constitute an important target for the prevention of suicide in the old elderly. Intervention studies with large numbers of senior participants are sorely needed.

Subcortical lesion severity and orbitofrontal cortex volume in geriatric depression

Previous studies have shown a reduction of orbital frontal cortex volume and an increase in magnetic resonance imaging signal hyperintensities in geriatric depression. We aimed to assess the relationship between subcortical gray- and deep white-matter lesions and orbital frontal cortex volume in elderly depressives and controls. The study included 41 elderly depressed patients and 41 age-matched control subjects. The orbital frontal cortex volume was measured in both hemispheres using a standardized MRI procedure. Signal hyperintensities were rated on (T2)-weighted MRI with qualitative lesion analyses performed according to an established hyperintensity classification system. After controlling for total cerebral hemisphere, age and sex, the geriatric depressed subjects had significant reduction in orbital frontal cortex volume and compared with the control group. Multiple linear regression modeling indicated that reduced orbital frontal cortex volumes were significantly associated with increased subcortical gray-matter lesions. Our study confirmed the reduction of OFC volume in geriatric depressed subjects. We also suggest that subcortical lesions may decrease OFC volume. Further studies are needed to understand how subcortical lesions may be related to OFC volume changes.

Panic disorder in public sector primary care: clinical characteristics and illness severity compared with "mainstream" primary care panic disorder

The prevalence of anxiety disorders is increased among low-income individuals, who are more likely to seek mental health care in medical as opposed to specialty settings because of limited insurance access and restricted availability of public sector mental health resources. However, little is known about the clinical characteristics and illness severity of anxiety disorders in this setting. We studied the clinical characteristics of low-income compared with middle-income primary care panic patients. Clinical, functional, and service use measures obtained at baseline interview in 39 panic disorder patients seen in one public sector medical clinic were compared with 76 patients seen in two middle-income clinics. All patients were participants in a randomized effectiveness pharmacotherapy trial [Roy Byrne et al., Arch Gen Psychiatry 2001;58:869-876]. Public sector patients were more often older, male, single, unemployed, of lower income, and non-Caucasian ethnicity. They had more severe clinical symptoms, more medical comorbidity, worse physical and role health status, and more emergency room visits. Low income and unemployment accounted for most of the differences in non-anxiety-related measures. However, type of clinic still contributed independently to the greater severity of specific measures of panic/anxiety (Panic Disorder Severity Scale and Marks Fear Scale scores), suggesting that the increased stress and limited social resources associated with low-income and disadvantaged status may have more specific effects on anxiety than other aspects of psychopathology.

Residual symptoms in elderly major depression remitters

OBJECTIVE

To assess residual symptoms in severe geriatric major depression in remission, and to determine baseline clinical and sociodemographic predictors of residual symptoms in remitters.

METHOD

A total of 108 elderly patients with unipolar major depression were evaluated and treated naturalistically for 9 months so as to record the predictors of residual symptoms in remitters. In order to reduce the likelihood of confusing residual symptoms with normal effects of age, 30 control subjects were also monitored.

RESULTS

Seventy-nine patients (73.1%) were considered remitters and 82.3% of remitters showed residual symptoms. Medical burden, chronic stress and subjective social support were the only variables which predicted the severity of residual symptoms in remitters.

CONCLUSION

Residual symptoms in elderly patients with major depression in remission should not only be attributed exclusively to intrinsic factors of the illness or the age of the individual patient, but also to external factors.

A model of risk for major depression: effects of life stress and cognitive style vary by age

Empirical studies increasingly attribute risk for depression to adverse life events, cognitive style, and possibly to the interaction between cognitive style and event type. We present an evidence-based model, developed with independent samples of adults and elderly adults, indicating that risk for major depression associated with these factors varies with age. According to the model, adverse events and need for control, the cognitive style that is a key feature of Beck's concept of autonomy, are significant risk factors for depression in younger adults but not in elderly adults. The cognitive style of sociotropy, characterized by a high need for relatedness and concern about disapproval, is a stable risk factor, independent of age, in posing a risk for depression. The effects of the interactions of adverse event type (achievement events and interpersonal events) and cognitive style in predicting depression each appear to vary with age, expanding prior work, which suggests that adverse events affecting one's personal vulnerability are likely to precipitate depression. Age-specific approaches to reducing risk for major depression are clinically important, and the model presented here suggests that the use of an age-specific perspective would advance research in stress-diathesis models for risk of depression.

Apathy and executive function in depressed elderly

Apathy and executive cognitive dysfunction (ECD) are important though conceptually different aspects of late-life depression. The primary objective of this study was to evaluate the relationship of apathy to ECD. The authors also evaluated the relationship of apathy and ECD to global cognitive impairment and word generation. Fifty-two elderly subjects with major depression and MMSE scores of 15 or greater were evaluated with apathy-related items from the Hamilton rating scale for depression (ApHRSD), the Executive Interview (EXIT), the Dementia Rating Scale (DRS), and the Controlled Oral Word Association test (COWA). ApHRSD scores were not significantly correlated with any of these variables. EXIT scores were correlated significantly with DRS and COWA. The results suggest that apathy and ECD may be independent of each other in some samples of elderly with late-life depression. Correlations may have been reduced by low variance for the variables of interest and by psychometric limitations of the ApHRSD.

Apathy and cognitive performance in older adults with depression

OBJECTIVES

Recent studies have linked apathy to frontal lobe dysfunction in persons with dementia, but few studies have explored this relationship in older, depressed persons without dementia. We examined the association between apathy and cognitive function in a group of older persons with major depression using standardized neuropsychological tests. We hypothesized that presence of apathy in depression is associated with poorer frontal executive performance.

METHODS

We analyzed data from 89 older adults with major depression. We defined apathy using four items from the Hamilton Psychiatric Rating Scale for Depression which reflect the clinical state of apathy, including 'diminished work/interest,' 'psychomotor retardation,' 'anergy' and 'lack of insight.'

RESULTS

Apathy most strongly correlated with two verbal executive measures (Stroop C and FAS), a nonverbal executive measure (Wisconsin Card Sorting Test-Other Responses), and a measure of information processing speed (Stroop B). Apathy was not associated with age, sex, education, medical illness burden, Mini-Mental State Examination score and Full Scale IQ score. Stepwise regression analyses of significant cognitive tests showed that apathy alone or apathy plus depression severity, age, or education accounted for a significant amount of the variance.

CONCLUSIONS

The results of this study provide support for an apathy syndrome associated with poorer executive function in older adults with major depression.

Prediction of mortality in nursing home residents: impact of passive self-harm behaviors

OBJECTIVE

The aim of this study was to determine whether indirect self-destructive behaviors predict mortality in nursing home residents.

METHOD

This cross-sectional study with follow-up after 2 years and 3 months surveyed 593 residents in 10 nursing homes in the eastern suburbs of Sydney, Australia. The following instruments were used: Harmful Behaviors Scale (HBS), Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD), Functional Assessment Staging Scale, Resident Classification Index, Cumulative Illness Rating Scale, Even Briefer Assessment Scales for Depression, and the suicide item from the Structured Hamilton Depression Rating Scale. Diagnoses of depression, dementia, and psychosis were obtained from nursing home records. Mortality data were obtained in August 1999.

RESULTS

At follow-up, 297 (50.1%) residents were still alive with a mean survival time of 565.4 days. Survival analyses found that mortality was predicted by older age, male gender, lower level of functioning, lower levels of behavioral disturbance on the BEHAVE-AD, and higher scores on the HBS "passive self-harm" factor-based subscale, which includes refusal to eat, drink, or take medication.

DISCUSSION

These results suggest that passive self-harm behaviors predict mortality in nursing home residents.

Axis III disorders in treatment-resistant major depressive disorder

A number of naturalistic studies have found that medical co-morbidity conveys a worse long-term prognosis in the treatment of major depressive disorder (MDD). The purpose of this study was to test whether the presence of co-morbid medical conditions can predict clinical response in patients with treatment-resistant MDD (TRD) treated with open-label nortriptyline (NT). Ninety-two patients with TRD entered a 6-week open trial of NT. The presence of co-morbid medical disorders was assessed during the screen visit. The degree of medical co-morbidity during the screen visit was then quantified with the use of the Cumulative Illness Rating Scale-Geriatric Version (CIRS(G)). We tested whether CIRS(G) scores predicted clinical response or depression severity at endpoint. CIRS scores at baseline did not significantly predict treatment response. The results of this study fail to confirm the relationship between co-morbid medical conditions and poor outcome in the treatment of MDD for patients with TRD. Patients with TRD and co-morbid medical conditions can be expected to respond to antidepressants as well as their counterparts without concurrent axis III co-morbidity. The CIRS(G) scores for this TRD sample were lower than those reported for geriatric depression, or for depressed patients with severe medical illness, common in medical and surgical wards and in most specialty clinics of large academic centers. Thus, the present results cannot be generalized to such populations.

Comorbidity in post-stroke rehabilitation

Patients referred to rehabilitation centers often suffer from associated comorbidity, which might negatively influence the effective outcome of the treatment program. The study was aimed at evaluating the impact of comorbidity on functional independence and gain after stroke. Ninety-three patients admitted to rehabilitation were enrolled. The disability was evaluated, both at time of admission and at discharge. The functional independence measure (FIM) was used. Comorbidity was evaluated by means of the Cumulative Illness Rating Scale (CIRS), that generates two indexes, the cumulative index (CI) and the severity index (SI). A logistic model could discriminate patients who were regularly discharged from the others (dead or transferred to acute care) pooled together (P < or = 0.02). The CI and SI were significantly correlated with FIM at admission. The r-values were -0.24 (P < or = 0.02) and -0.32 (P < 0.002). Recovery was not even influenced in the most severe patients. In conclusion, the CIRS appears to be a sensitive tool for the evaluation of comorbidity in stroke patients. The comorbidity is correlated to dependence in stroke patients but does not affect functional gain. However, comorbidity is of actual interest in view of new payment systems in rehabilitation, because it is included among the variables leading to costs.

Somatic symptoms in treatment-resistant depression

The purpose of this work was to study the prevalence of somatic symptoms in patients with treatment-resistant depression (TRD) and their impact on the response to antidepressant treatment. Somatic symptoms were assessed during the screen visit with the Symptom Questionnaire (SQ) somatic symptom (SQ-SS) and somatic well-being sub-scales (SQ-SWB) in 40 patients with TRD enrolled in a 6-week open trial of nortriptyline. A logistic regression was used to test whether SQ-SS or SQ-SWB scores predicted clinical response to nortriptyline. Ninety-five percent of patients reported at least one somatic symptom. Higher SQ-SS scores during the screen visit predicted poorer response to nortriptyline. There was a trend for lower SQ-SWB scores to predict poor response to nortriptyline. None of the patients with SQ-SS scores above the mean for the sample responded to nortriptyline. The overwhelming majority of patients with TRD presented with somatic symptoms. In addition, a greater number of somatic symptoms during the screen visit placed patients at risk for further treatment resistance.

Geriatric oncology: a clinical approach to the older patient with cancer

Due to the ageing of the population and the sharp increase in life expectancy, cancer in the older person has become an increasingly common problem in the Western world. Although several authors have stressed that elderly cancer patients deserve special attention as a target group for research efforts, older aged patients are still less likely to be offered participation in clinical trials. The cellular and molecular mechanisms regulating the physiological process of ageing and senescence are far from understood, although inflammation is likely to play an important role, at least in some cancers. In addition, the relationship between ageing and cancer risk is also far from understood. One of the most intriguing aspects of ageing is how different the ageing process is from person to person; the basis for this variation is largely unknown. Population-based studies and longitudinal surveys have shown that comorbidity and physical and mental functioning are important risk factors; thus, a meaningful assessment of comorbidity and disability should be implemented in clinical practice. Modern geriatrics is targeted towards patients with multiple problems. Such patients are not simply old, but are geriatric patients because of interacting psychosocial and physical problems. As a consequence, the health status of old persons cannot be evaluated by merely describing the single disease, and/or by measuring the response, or survival after treatment. Conversely, it is necessary to conduct a more comprehensive investigation of the 'functional status' of the aged person. A geriatric consultation provides a variety of relevant information and enables the healthcare team to manage the complexity of health care in the elderly; this process is referred to as the Comprehensive Geriatric Assessment (CGA). The use of CGA is now being introduced into oncological practice. The definition of frailty is still controversial and represents a major issue of debate in clinical geriatrics. As the frail population increases, clinical trials in frail persons are needed. The usefulness of these trials requires a consensus as to the definition of frailty. Clearly, the management of older persons with cancer requires the acquisition of special skills in the evaluation of the older person and in the recognition and management of emergencies as well as experience in geriatric case management.

Personality is associated with perceived health and functional status in older primary care patients

Using data collected on 265 primary care medical patients 60 years of age and older, the authors examined the personality bases of subjective health (perceived health, functional status) after controlling for observer-rated depression and medical burden. Four hypotheses were tested: High Neuroticism is associated with poorer perceived health, low Extraversion is associated with poorer perceived health, low Openness to Experience is associated with worse functional status, and age moderates the relationships between personality and subjective health. Findings supported the notion that personality is associated with subjective health; moreover, this effect appeared to grow more pronounced with increasing age. This study underscores the conceptual and heuristic value of examining moderators of the links between personality variables and health.

Impact of comorbidity on lung cancer survival

Lung cancer is associated with smoking and age, both of which are associated with comorbidity. We evaluated the impact of comorbidity on lung cancer survival. Data on 56 comorbidities were abstracted from the records of a cohort of 1,155 patients. Survival effects were evaluated with Cox regression (outcome crude death). The adjusted R(2) statistic was used to compare the survival variation explained by predictive variables. No comorbidity was observed in 11.7% of patients, while 54.3% had 3 or more (mean 2.97) comorbidities. In multivariate analysis, 19 comorbidities were associated with survival: HIV/AIDS, tuberculosis, previous metastatic cancer, thyroid/glandular diseases, electrolyte imbalance, anemia, other blood diseases, dementia, neurologic disease, congestive heart failure, COPD, asthma, pulmonary fibrosis, liver disease, gastrointestinal bleeding, renal disease, connective tissue disease, osteoporosis and peripheral vascular disease. Only the latter was protective. Some of the hazards of comorbidities were explained by more directly acting comorbidities and/or receipt of treatment. Stage explained 25.4% of the survival variation. In addition to stage, the 19 comorbidities explained 6.1%, treatments 9.2%, age 3.7% and histology 1.3%. Thirteen uncommon comorbidities (prevalence <6%) affected 21.2% of patients and explained 3.5% of the survival variation. Comorbidity count and the Charlson index were significant predictors but explained only 2.5% and 2.0% of the survival variation, respectively. Comorbidity has a major impact on survival in early- and late-stage disease, and even infrequent deleterious comorbidities are important collectively. Comorbidity count and the Charlson index failed to capture much information. Clinical practice and trials need to consider the effect of comorbidity in lung cancer patients.

Can older cancer patients tolerate chemotherapy? A prospective pilot study

BACKGROUND

To the authors' knowledge, few data currently are available regarding the tolerance to chemotherapy in older cancer patients. This prospective pilot study evaluated the changes in functional, mental, nutritional, and comorbid status, as well as the quality of life (QOL), in geriatric oncology patients receiving chemotherapy.

METHODS

Sixty patients age > or = 70 years who were undergoing cancer chemotherapy were recruited in a university-based comprehensive cancer center. Changes in physical function were measured by the Eastern Cooperative Oncology Group performance status (ECOG PS) and Instrumental Activities of Daily Living (IADLs), mental health changes were measured by the Mini-Mental State Examination and the Geriatric Depression Scale (GDS), comorbidity was measured by Charlson's index and the Cumulative Illness Rating Scale-Geriatric, nutrition was measured by the Mini-Nutritional Assessment, and QOL was measured by the Functional Assessment of Cancer Therapy-General (FACT-G). Changes were assessed at baseline and at the end of treatment (EOT). Grade 4 hematologic and Grade 3-4 nonhematologic toxicities were recorded.

RESULTS

Thirty-seven patients (63%) completed both assessments. Older cancer patients demonstrated a significant decline in measurements of physical function after receiving chemotherapy, as indicated by changes in scores on the IADL (P = 0.04) and on the physical (P = 0.01) and functional (P = 0.03) subscales of the FACT-G. They also displayed worse scores on the GDS administered postchemotherapy (P < 0.01). Patients who experienced severe chemotoxicity had more significant declines in ECOG PS (P = 0.03), IADL (P = 0.03), and GDS (P = 0.04), and more gain in the social well-being subscale (P = 0.02) of the FACT-G, than those who did not experience severe chemotoxicity. However, changes in most scores were small in magnitude clinically. No significant change was found between baseline and EOT in nutrition, comorbidity, and other aspects of the FACT-G.

CONCLUSIONS

Older cancer patients undergoing chemotherapy may experience toxicity but generally can tolerate it with limited impact on independence, comorbidity, and QOL levels. It is important to recognize and monitor these changes during geriatric oncology treatment.

Does an exercise and incontinence intervention save healthcare costs in a nursing home population?

OBJECTIVES

To determine whether an intervention that combines low-intensity exercise and incontinence care offsets some of its costs by reducing the incidence of selected health conditions in nursing home residents.

DESIGN

Randomized, controlled trial with the incidence and costs of selected, acute conditions compared between a 6-month baseline and an 8-month intervention phase.

SETTING

Four nursing homes.

PARTICIPANTS

One hundred ninety incontinent, long-stay nursing home residents.

INTERVENTION

Low-intensity, functionally oriented exercise and incontinence care were provided every 2 hours from 8:00 a.m. to 4:00 p.m. for 5 days a week for 8 months.

MEASUREMENTS

Predefined acute conditions hypothesized to be related to physical inactivity, incontinence, or immobility were abstracted from residents' medical records by blinded observers during a 6-month baseline period and throughout the 8-month intervention. Conditions included those in the dermatological, genitourinary, gastrointestinal, respiratory and cardiovascular systems; falls; pain; and psychiatric and nutritional disturbances. Costs were determined using Current Procedural Terminology Center and Medicare allowable cost reimbursement at a rate of 80%.

RESULTS

The intervention group had significantly better functional outcomes than the control group (strength, mobility endurance, urinary and fecal incontinence) and a reduction of 10% in the incidence of the acute conditions, which was not significant. There were no significant differences between groups in the cost of assessing and treating these acute conditions between baseline and intervention.

CONCLUSION

The intervention, which is consistent with federal and clinical practice guidelines, significantly improved functional outcomes but did not reduce the incidence and costs of selected acute health conditions. The cost of implementing these labor-intensive interventions for frail nursing home residents will have to be justified based on functional and quality-of-life outcomes and are unlikely to be offset by savings in medical care costs in this population.

Smaller orbital frontal cortex volumes associated with functional disability in depressed elders

BACKGROUND

Depression is associated with significant functional impairment. Recent evidence has linked the orbital frontal cortex (OFC) with depression. We examined the relationship between OFC volumes in older subjects and impairment in the basic (BADL) and instrumental (IADL) activities of daily living.

METHODS

The sample consisted of 81 subjects aged 60 years or older; 41 were depressed subjects and 40 healthy control subjects. In a structured interview, subjects reported their medical history and ability to perform both BADL and IADL. Subjects then had a brain magnetic resonance imaging (MRI) scan; the OFC was manually traced bilaterally using neuroanatomical landmarks. Logistic regression was used to examine the effect of OFC volume on BADL and IADL while controlling for the effects of total brain volume, subject status, medical comorbidity, and demographic factors.

RESULTS

Smaller OFC volumes, along with greater cognitive impairment as measured by the Mini-Mental State Examination, were significantly associated with BADL impairment. Smaller OFC volumes and being depressed were significantly associated with IADL impairment.

CONCLUSIONS

Smaller OFC volumes are independently associated with functional impairment, supporting its role in depression. Further studies are needed to determine how smaller OFC volumes are related to other MRI abnormalities associated with depression and functional impairment.

Healthy older adults' sleep predicts all-cause mortality at 4 to 19 years of follow-up

OBJECTIVE

Evidence concerning whether sleep disturbances in older adults predict mortality is mixed. However, data are limited to self-reported sleep problems and may be confounded with other comorbidities. We examined whether electroencephalographic (EEG) sleep parameters predicted survival time independently of known predictors of all-cause mortality.

METHODS

A total of 185 healthy older adults, primarily in their 60s through 80s, with no history of mental illness, sleep complaints, or current cognitive impairment, were enrolled in one of eight research protocols between October 1981 and February 1997 that included EEG sleep assessments. At follow-up (mean [SD] = 12.8 [3.7] years after baseline, range = 4.1-19.5), 66 individuals were positively ascertained as deceased and 118 remained alive (total N = 184).

RESULTS

Controlling for age, gender, and baseline medical burden, individuals with baseline sleep latencies greater than 30 minutes were at 2.14 times greater risk of death (p =.005, 95% CI = 1.25-3.66). Those with sleep efficiency less than 80% were at 1.93 times greater risk (p =.014, CI = 1.14-3.25). Individuals with rapid eye movement (REM) sleep percentages in the lowest 15% or highest 15% of the total sample's distribution (percentage of REM <16.1 or >25.7) were at 1.71 times greater risk (p =.045, CI = 1.01-2.91). Percentage of slow-wave sleep was associated with time to death at the bivariate level, but not after controlling for potential confounders.

CONCLUSIONS

Older adults with specific EEG sleep characteristics have an excess risk of dying beyond that associated with age, gender, or medical burden. The findings suggest that interventions to optimize and protect older adults' sleep initiation, continuity, and quality may be warranted.

The establishment of a brain bank for the study of late-life depression: a feasibility study of factors facilitating consent

BACKGROUND

Studies of postmortem brain tissue are advancing the understanding of the pathophysiology of major depressive disorder (MDD). The nature and quality of subject samples, however, limit their applicability to late-life MDD.

OBJECTIVE

To examine the feasibility of establishing a brain bank for late-life MDD, and identify clinical, demographic, and procedural factors that might facilitate subject enrollment.

METHODS

Elderly subjects participating in clinical trials associated with the Mental Health Intervention Research Center for Late-Life Mood Disorders (MHIRC/LLMD) at the University of Pittsburgh were approached by clinical research staff for consent to future brain-only autopsy. Subjects who consented to participation were compared with those who refused participation on demographic and clinical variables. MHIRC/LLMD clinical research staff were interviewed to determine factors that may have facilitated or hindered the consent process and reasons for subject consent or refusal.

RESULTS

Eighty out of 242 subjects (33%) subjects approached for participation in the brain bank provided consent. Consent to participate was associated with higher level of education and with lower Mini-Mental State Examination score. Several factors facilitating and hindering the consent process were identified.

CONCLUSION

We provide preliminary evidence for the feasibility of establishing a brain bank for the study of late-life MDD. Future efforts may be guided by the factors identified as facilitating the consent process, especially the inclusion of family in the consent process.

Measuring comorbidity in patients with head and neck cancer

BACKGROUND

Comorbidities are diseases or conditions that coexist with a disease of interest. The importance of comorbidities is that they can alter treatment decisions, change resource utilization, and confound the results of survival analysis.

OBJECTIVE

The objective of this study was to determine the best comorbidity index to use in survival analysis of patients with squamous cell carcinoma of the head and neck.

METHOD

Four validated indexes, with very different methodologies (i.e., the Charlson Index, the Cumulative Illness Rating Scale, the Kaplan-Feinstein Classification, the Index of Co-existent Disease), were tested using data from 379 unselected consecutive patients with complete 3-year follow-up from the Kingston Regional Cancer Center. Kaplan-Meier analysis and Cox Proportional Hazards Regression were used to stratify patients into three levels of increasing severity of comorbidity for each index. The Proportion of Variance Explained and Receiver Operating Characteristics curves were used to compare the performance of the indexes.

CONCLUSION

The Kaplan-Feinstein Classification was the most successful in stratifying patients in this population.

Stressful life events interacting with cognitive/personality styles to predict late-onset major depression

The current work evaluated the interaction of life stressors with cognitive/personality styles in predicting late-onset depression in 42 elderly outpatients with DSM-IV unipolar Major Depression and 42 nondepressed controls. Control subjects were matched to cases on age, sex, race, and years of education. As suggested by Beck's cognitive theory of depression, a multivariate model indicated that specific stressful-event types interacted with specific cognitive/personality styles in strongly predicting depression onset, adjusting for the positive associations of medical illness and reduced physical functioning with depression.

Comorbidity and Karnofksy performance score are independent prognostic factors in stage III non-small-cell lung cancer: an institutional analysis of patients treated on four RTOG studies

PURPOSE

To determine the prognostic role of comorbidity in Stage III non-small cell lung cancer (NSCLC) treated definitively with radiotherapy alone.

METHODS AND MATERIALS

A total of 112 patients with clinical Stage III NSCLC (American Joint Commission on Cancer 1997) enrolled in four Radiation Therapy Oncology Group studies (83-11, 84-03, 84-07, and 88-08 nonchemotherapy arms) at a single institution were analyzed retrospectively for overall survival (OS) and comorbidity. Of the 112 patients, 105 (94%) completed their assigned radiotherapy. The median assigned dose was 50.4 Gy to the lymphatics (range 45-50.4 Gy) and 70.2 Gy to the primary tumor (range 60-79.2 Gy). Comorbidity was rated retrospectively using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) and Charlson scales. Karnofsky performance scores (KPSs) and weight loss were prospectively recorded. Because only 8 patients had a KPS of <70, these patients were combined with patients who had a KPS of 70. The OS of this group was compared with that of the patients with better KPSs (>70).

RESULTS

The median survival was 10.39 months (range 7.87-12.91). The 2-, 3-, and 5-year OS rate was 20.5%, 12.5%, and 7.1%, respectively. On univariate analysis, clinical stage (IIIA vs. IIIB) was found to be a statistically significant factor influencing OS (p = 0.026), and the histologic features, grade, tumor size as measured on CT scans, age, tobacco use, weight loss >or=5%, and total dose delivered to the primary tumor were not. A KPS of <or=70 (p = 0.001), the presence of a CIRS-G score of 4 (extremely severe; p = 0.0002), and a severity index of >2 (p <0.0001) were associated with statistically significant inferior OS. Multivariate analysis with clinical stage, KPS, and comorbidity (severity index) of all patients showed that a KPS <or=70 and severity index >2 were independently associated with inferior OS; clinical tumor stage was not found to be an independent prognostic factor.

CONCLUSION

KPS and comorbidity are important independent prognostic factors in Stage III NSCLC. Comorbidity should be included in protocols studying advanced stage NSCLC and used for stratification.

Effect of nortriptyline and paroxetine on CYP2D6 activity in depressed elderly patients

This study was performed in elderly patients (1) to assess the degree to which CYP2D6 mediated metabolism of debrisoquine at baseline determines plasma concentration to dose quotients for nortriptyline or paroxetine after 4 weeks of treatment, and (2) to compare the effects of nortriptyline and paroxetine on debrisoquine metabolism after 6 weeks of treatment. CYP2D6 activity was estimated in 66 subjects (71.4 +/- 7.2 years) before initiating treatment and again after 6 weeks of treatment with either nortriptyline or paroxetine under randomized, double-blind conditions according to a standard protocol. CYP2D6 activity was estimated by the debrisoquine recovery ratio in a 6- to 8-hour urine sample collected after oral administration of 10 mg debrisoquine sulfate. Nortriptyline and paroxetine plasma concentrations were obtained weekly. Baseline debrisoquine recovery ratio values were significantly correlated with the plasma concentration to dose quotient at 4 weeks for both nortriptyline ( = -0.75, = 0.0001, N = 29) and paroxetine ( = -0.50, = 0.003, N = 33). Treatment with either nortriptyline or paroxetine was associated with a significant decrease in the median debrisoquine recovery ratio, reflecting inhibition of CYP2D6 metabolism. The percent decrease associated with nortriptyline was significantly smaller than that with paroxetine ( < 0.0001). None of the patients treated with nortriptyline but 19 of the 32 extensive metabolizers treated with paroxetine were converted to phenotypic poor metabolic status. Our observations of CYP2D6 inhibition are consistent with data and results obtained in younger healthy volunteers. The significant correlations between baseline debrisoquine recovery ratio and the plasma concentrations to dose quotients at 4 weeks for both nortriptyline and paroxetine are consistent with CYP2D6 playing a major role in the metabolism of both drugs. CYP2D6 inhibition by paroxetine, which effectively converted 59% of patients to phenotypic PMs, may be especially relevant for elderly patients given their generally higher concentration of paroxetine.

Translating clinical research into practice: a randomized controlled trial of exercise and incontinence care with nursing home residents

OBJECTIVES

To examine clinical outcomes and describe the staffing requirements of an incontinence and exercise intervention.

DESIGN

Randomized controlled trial with blinded assessments of outcomes at three points over 8 months.

SETTING

Four nursing homes.

PARTICIPANTS

Two hundred fifty-six incontinent residents.

INTERVENTION

Research staff provided the intervention, which integrated incontinence care and exercise every 2 hours from 8:00 a.m. to 4:00 p.m. 5 days a week.

MEASUREMENTS

Average and maximum distance walked or wheeled, level of assistance required to stand, maximum pounds lifted by arms, fecal and urinary incontinence frequency, and time required to implement intervention.

RESULTS

Intervention residents maintained or improved performance whereas the control group's performance declined on 14 of 15 outcome measures. Repeated measures analysis of variance group-by-time significance levels ranged from P <.0001 to.05. The mean time required to implement the intervention each time care was provided was 20.7 +/- 7.2 minutes. We estimate that a work assignment of approximately five residents to one aide would be necessary to provide this intervention.

CONCLUSIONS

The incontinence care and exercise intervention resulted in significant improvement for most residents, and most who could be reliably interviewed expressed a preference for such care. Fundamental changes in the staffing of most nursing homes will be necessary to translate efficacious clinical interventions into everyday practice.

A randomized, placebo-controlled trial of paroxetine in nursing home residents with non-major depression

Depression is common across a broad spectrum of severity among nursing home residents. Previous research has demonstrated the effectiveness of antidepressants in nursing home residents with major depression, but it is not known whether antidepressants are helpful in residents with less severe forms of depression. We conducted a randomized double-blind placebo-controlled 8-week trial comparing paroxetine and placebo in very old nursing home residents with non-major depression. The main outcome measure was the primary nurse's Clinical Impression of Change (CGI-C). Additional outcome measures were improvement on the interview-derived Hamilton Depression Rating Scale (HDRS) and Cornell Scale for Depression (CS) scores. Twenty-four subjects with a mean age of 87.9 were enrolled and twenty subjects completed the trial. Placebo response was high, and when all subjects were considered, there were no differences in improvement between the paroxetine and placebo groups. Two subjects that received paroxetine developed delirium, and subjects that received paroxetine were more likely to experience a decrease in Mini Mental State Exam scores (P =.03). There were no differences in serum anticholinergic activity between groups. In a subgroup analysis of 15 subjects with higher baseline HDRS and CS scores, there was a trend toward greater improvement in the paroxetine group in an outcome measure that combined the CGI-C and interview-based measures (P =.06). Paroxetine is not clearly superior to placebo in this small study of very old nursing home residents with non-major depression, and there is a risk of adverse cognitive effects. Because of the high placebo response and the trend towards improvement in the more severely ill patients, it is possible that a larger study would have demonstrated a significant therapeutic effect for paroxetine as compared with placebo. The study also illustrates the discordance between patient and caregiver ratings, and the difficulties in studying very elderly patients with mood disorders.

Estrogen replacement therapy is associated with less progression of subclinical structural brain disease in normal elderly women: a pilot study

BACKGROUND

Cortical atrophy, central atrophy, deep white-matter hyperintensities, and periventricular hyperintensities are reported in normal aging.

OBJECTIVES

We examined the effects of estrogen replacement therapy (ERT) on these forms of 'subclinical structural brain disease' (SSBD) in normal, postmenopausal women in a pilot, naturalistic, longitudinal study of 15 subjects.

METHODS

Two assessments were performed at least two years apart, with volumetric magnetic resonance imaging (MRI) and neuropsychological testing.

RESULTS

Women receiving open-label ERT showed significantly less progression of SSBD than those who did not.

CONCLUSIONS

The association between reduced SSBD progression and ERT suggests this intervention could help preserve normal brain structure in healthy elderly women.

Association of comorbidity and outcome in episodes of nonspecific low back pain in occupational populations

We examined the relationship between comorbidity and first return to work after episodes of work-disabling, nonspecific low back pain (NSLBP). An inception cohort of workers with new episodes of NSLBP was identified from administratively maintained occupational health records. We compared 6-month return-to-work rates between workers with one or more comorbid conditions with those without documented comorbidity. Workers with comorbidity were 1.31 times more likely to remain work disabled than those with uncomplicated NSLBP, after adjusting for age, gender, lifting demands, and company membership (adjusted hazards ratio [HR] = 1.31; 95% confidence interval [CI] 1.12 to 1.52). Concurrent injury (i.e., sprains or strains of the neck, upper extremity, and lower extremity; contusions; and lacerations) had the strongest association (adjusted HR = 1.49; 95% CI, 1.21 to 1.83), followed by musculoskeletal disorders (adjusted HR = 1.13; 95% CI, 0.77 to 1.66). Comorbidities should be routinely evaluated at first visit by occupational health professionals to better manage disability associated with LBP.

Predictors of tolerance to chemotherapy in older cancer patients: a prospective pilot study

Few data are available to help predict which older cancer patient is at risk of developing chemotherapy-related toxicity. This study was a pilot for a project designing a predictive risk score. Chemotherapy patients aged 70 years and older were prospectively enrolled. Chemotherapies were adjusted for their published toxicity. 60 patients were enrolled, 59 were evaluable. Mean dose-intensity was 90.3%, range 33.3-129.0%. 47% of the patients experienced grade 4 haematological and/or grade 3-4 non-haematological toxicity. Published toxicity (MAX2), diastolic blood pressure, marrow invasion and lactate dehydrogenase (LDH) were all associated with toxicity (P<0.1); Body Mass Index, previous chemotherapy, red blood cells, platelets, polymedication with dose-intensity; and polymedication with FACT-G change. After adjustment for the published toxicity, the variables retained their significance, except for LDH and polymedication (for dose-intensity). Although the size of this pilot study imposes a cautious interpretation, patient-related and chemotherapy-related variables correlated independently with toxicity. Designing a composite predictive score to use in assessing the toxicity of multiple chemotherapy regimens therefore appears to be a valid undertaking.

Burden of illness and suicide in elderly people: case-control study

OBJECTIVES

To study the association between physical illness and suicide in elderly people.

DESIGN

Case-control with illness determined from interviews with relatives of people who committed suicide and with control participants and from medical records.

SETTING

Gothenburg and two surrounding counties (210 703 people aged 65 years and over).

PARTICIPANTS

Consecutive records of people who had committed suicide and had undergone forensic examination (46 men, 39 women) and living control participants from the tax register (84 men, 69 women).

MAIN OUTCOME MEASURES

Physical illness rated in 13 organ systems according to the cumulative illness rating scale-geriatrics; serious physical illness (organ category score 3 or 4); overall score for burden of physical illness.

RESULTS

Visual impairment (odds ratio 7.0, 95% confidence interval 2.3 to 21.4), neurological disorders (3.8, 1.5 to 9.4), and malignant disease (3.4, 1.2 to 9.8) were associated with increased risk for suicide. Serious physical illness in any organ category was an independent risk factor for suicide in the multivariate regression model (6.4, 2.0 to 20.0). When the sexes were analysed separately, serious physical illness was associated with suicide in men (4.2, 1.8 to 9.5) as was high burden of physical illness (2.8, 1.2 to 6.5). Such associations were not seen in women, possibly because of the small sample size.

CONCLUSIONS

Visual impairment, neurological disorders, and malignant disease were independently associated with increased risk of suicide in elderly people. Serious physical illness may be a stronger risk factor for suicide in men than in women.

Subcortical white matter lesions and functional impairment in geriatric depression

Geriatric depression is associated with significant functional impairment. There is also growing evidence linking vascular brain changes to depression in late life. We sought to examine the relationship between cerebrovascular disease and impairment in basic activities of daily living (BADL) and instrumental activities of daily living (IADL) in a group of older depressives. The sample consisted of 224 depressed adults aged 60 years and above enrolled in Duke's Mental Health Clinical Research Center. All subjects had unipolar major depression and were free of other major psychiatric and neurological illness, including dementia. In a structured interview, subjects reported their medical history and ability to perform both BADL and IADL. Geriatric psychiatrists assessed cognition using the Mini Mental State Examination (MMSE) and depression severity using the Montgomery Asberg Depression Rating Scale (MADRS). Subjects had a standardized magnetic resonance imaging (MRI) brain scan. MRI scans were processed using a semi-automated method to determine volumes of subcortical white matter lesions (WML) and subcortical gray matter lesions (GML). Logistic regression was used to examine effects of WML and GML controlling for demographic and clinical factors. Greater volume of WML was associated with impairment in both BADL and IADL, while GML was associated with IADL impairment. In logistic models, WML remained significantly associated with IADL after controlling for the effects of age, gender, depression severity, and medical comorbidity. We concluded that white matter lesions are independently associated with functional impairment. Further studies are needed to understand how these lesions affect function, e.g., through effects on cognition or motor skills.

Course and rate of antidepressant response in the very old

OBJECTIVE

The authors examined elderly patients with major depression to determine the relationship of current age to treatment response course and success rate.

METHODS

Three studies of elderly depressed patients provided data on antidepressant treatment response in 323 subjects, treated in protocols using either nortriptyline or paroxetine. We grouped the subjects by current age: 'young-old' (59-69, N=163), 'middle-old' (70-75, N=80), and 'older-old' (76-99, N=80). We employed mixed-effect random regression analyses to examine Hamilton Rating Scale for Depression scores over 12 weeks of acute treatment.

RESULTS

Older-old patients responded as quickly and successfully as the young- and middle-old.

CONCLUSIONS

Major depression in the very old can be treated as successfully as in early old age.

Health status and functional status in relationship to nursing home subacute rehabilitation program outcomes

OBJECTIVE

To assess the relationship of health status and functional status to key nursing home subacute rehabilitation program outcomes: motor function at discharge, discharge destination, and length of stay in the program.

DESIGN

Using a prospective cohort study design, 164 patients were assessed on entering the rehabilitation program for the first time after discharge from an acute hospital. Their median length of stay was 40 days.

RESULTS

The patients' motor function improved over time (P < 0.0001), and a large majority were discharged to the community. At admission, health status was positively associated with motor function (P < 0.05) and cognitive function (P < 0.01). Higher cognitive function and higher motor function at admission were correlated with higher motor function at discharge (rs = 0.386, P < 0.0001; rs = 0.563, P < 0.0001 respectively). Better health status was independently associated with discharge to the community (P < 0.01). Only motor function at admission was independently associated with length of stay (P < 0.01).

CONCLUSION

Health status and functional status are related, and both are independently associated with nursing home subacute rehabilitation program outcomes. Therefore, an improvement in one may result in an improvement in the other, and both aid in the attainment of positive subacute rehabilitation outcomes.

Comorbidity and KPS are independent prognostic factors in stage I non-small-cell lung cancer

PURPOSE

To determine the prognostic role of comorbidity in Stage I non-small-cell lung cancer (NSCLC) treated with surgery or radiotherapy (RT).

MATERIALS AND METHODS

One hundred sixty-three patients with clinical Stage I NSCLC were analyzed for overall survival (OS) and comorbidity. One hundred thirteen patients underwent surgery (surgical group) and 50 patients received definitive radiotherapy (RT group). Ninety-six percent of the surgical group had lobectomy or pneumonectomy, and negative margins were achieved in 96% of the patients. The median dose to the tumor for the RT group was 61.2 Gy (range 30.8-77.4). The Cumulative Illness Rating Scale for Geriatrics (CIRS-G) and the Charlson scale were used to rate comorbidity. Karnofsky performance scores (KPS) were available in 42 patients; the rest of the scores were determined retrospectively by two physicians independently, with 97% agreement.

RESULTS

The OS was 44% for the surgical group and 5% for the RT group at 5 years. Noncancer-related mortality was observed in 31% and 62% of the surgical and RT patients, respectively. On univariate analysis, performed on all patients (n = 163), squamous cell histologic type (p <0.001), clinical Stage T2 (p = 0.062), tumor size >4 cm (p = 0.065), >40 pack-year tobacco use (p <0.001), presence of a CIRS-G score of 4 (extremely severe, CIRS-G4: [+]) (p <0.001), severity index of >2 (p <0.001), Charlson score >2 (p = 0.004), KPS <70 (p <0.001), and treatment with RT (p <0.001) were associated with a statistically significant inferior OS. Multivariate analysis with histologic features, clinical T stage, age, tobacco use, KPS, comorbidity [CIRS-G(4)] and treatment group on all patients showed that squamous cell histology, >40 pack-year tobacco use, KPS <70, and presence of CIRS-G(4) were independently associated with an inferior OS. Treatment modality, T stage, and age did not have any statistically significant effect on OS. Statistically significant differences were found between the surgical and RT groups in Charlson score (p = 0.001), CIRS-G total score (p = 0.004), severity index (p = 0.006), CIRS-G4(+) (p <0.001), KPS (p <0.001), amount of tobacco use (p = 0.002), clinical tumor size (p <0.001), clinical T stage (p = 0.01), forced expiratory volume in 1 s (p = 0.001), and age (p = 0.008), in favor of the surgical group.

CONCLUSION

The presence of significant comorbidity and KPS of <70 are both important prognostic factors, but were found to be independent of each other in Stage I NSCLC. Therefore, comorbidity and KPS assessment are recommended when analyzing the prognostic effects of tumor or treatment-related factors on OS.

A randomized, double-blind, placebo-controlled study of the efficacy and safety of donepezil in patients with Alzheimer's disease in the nursing home setting

OBJECTIVES

To evaluate the safety and efficacy of donepezil in the management of patients with Alzheimer's disease (AD) residing in nursing home facilities.

DESIGN

Twenty-four-week, randomized, multicenter, parallel-group, double-blind, placebo-controlled trial.

SETTING

Twenty-seven nursing homes across the United States.

PARTICIPANTS

Two hundred eight nursing home patients with a diagnosis of probable or possible AD, or AD with cerebrovascular disease; mean Mini-Mental State Examination (MMSE) score 14.4; mean age 85.7.

MEASUREMENTS

The primary outcome measure was the Neuropsychiatric Inventory-Nursing Home Version (NPI-NH). Secondary efficacy measures were the Clinical Dementia Rating (Nursing Home Version)-Sum of the Boxes (CDR-SB), MMSE, and the Physical Self-Maintenance Scale (PSMS). Safety was monitored by physical examinations, vital signs, clinical laboratory tests, electrocardiograms (ECGs), and treatment-emergent adverse events (AEs).

RESULTS

Eighty-two percent of donepezil- and 74% of placebo-treated patients completed the trial. Eleven percent of donepezil- and 18% of placebo-treated patients withdrew because of AEs. Mean NPI-NH 12-item total scores improved relative to baseline for both groups, with no significant differences observed between the groups at any assessment. Mean change from baseline CDR-SB total score improved significantly with donepezil compared with placebo at Week 24 (P < .05). The change in CDR-SB total score was not influenced by age. Differences in mean change from baseline on the MMSE favored donepezil over placebo at Weeks 8, 16, and 20 (P < .05). No significant differences were observed between the groups on the PSMS. Overall rates of occurrence and severity of AEs were similar between the two groups (97% placebo, 96% donepezil). Gastrointestinal AEs occurred more frequently in donepezil-treated patients. In general, AEs were similar in older and younger donepezil-treated patients, with the majority of patients experiencing only AEs that were transient and mild or moderate in severity. Weight loss was reported as an AE more frequently in older patients, although a loss at last visit of >or=7% of screening weight occurred at the same rate in older and younger patients (9% of donepezil- and 6% of placebo-treated patients). No significant differences between groups in vital sign changes, bradycardia, or rates of clinically significant laboratory or ECG abnormalities were observed.

CONCLUSION

Patients treated with donepezil maintained or improved in cognition and overall dementia severity in contrast to placebo-treated patients who declined during the 6-month treatment period. The safety and tolerability profile was comparable with that reported in outpatient studies of donepezil. These findings also suggest that advanced age, comorbid illnesses, and high concomitant medication usage should not be barriers to donepezil treatment. Given the apparent improvement in behavior in the placebo group, and the high use of concomitant medications in both groups, the impact of donepezil on behavior in the nursing home setting is unresolved and merits further investigation. In summary, effects on cognition, overall dementia severity, and safety and tolerability findings are consistent with previous findings in outpatients and support the use of donepezil in patients with AD who reside in nursing homes.