Assessment and management of patients with cognitive impairment and dementia in primary care

OBJECTIVES

To evaluate care provided by primary care physicians in community practice to older patients presenting with cognitive impairment and dementia.

DESIGN

Secondary analysis of an intervention study.

SETTING

Primary care clinics.

PARTICIPANTS

101 patients 75 years and older enrolled in the ACOVE-2 study who presented with a new cognitive problem, new dementia, or prevalent dementia.

MEASUREMENTS

Patients assessment and management were evaluated from medical record review and caregiver interviews.

RESULTS

Among 34 patients presenting with a new cognitive problem, half received a cognitive assessment comprising of a test of memory and one other cognitive task, 41% were screened for depression and 29% were referred to a consultant. Of the 27 patients with newly diagnosed dementia, 15% received the components of a basic neurological examination, one-fifth received basic laboratory testing and for one third the medical record reflected an attempt to classify the type of dementia. Counseling was under-reported in the medical record compared to the caregiver interview for the 101 patients with dementia, but even the interview revealed that about half or fewer patients received counseling about safety and accident prevention, caregiver support or managing conflicts. Less than 10% were referred to a social worker.

CONCLUSION

This small but detailed evaluation suggests patients presenting with cognitive problems to primary care physicians do not consistently receive basic diagnosis and management.

Cross-sectional association between markers of inflammation and serum sex steroid levels in the postmenopausal estrogen/progestin interventions trial

BACKGROUND

Standard risk factors do not adequately capture cardiovascular risk in postmenopausal women. We sought to determine the associations between levels of sex steroids and levels of inflammatory markers in postmenopausal women.

METHODS

We analyzed baseline data from a subset of postmenopausal women aged 45-64 years who had stored samples during a randomized controlled trial. We measured levels of C-reactive protein (CRP), interleukin-6 (IL-6), matrix metalloproteinase-9 (MMP-9), soluble intercellular adhesion molecule (sICAM), and circulating sex steroids. Multiple linear regression models were created with each of the following hormone levels as the primary exposure variable: estrone, total estradiol, bioavailable estradiol, total testosterone, bioavailable testosterone, progesterone, and sex hormone-binding globulin (SHBG). Sociodemographic and lifestyle covariates were derived from standardized self-report questionnaires and direct measurement (weight, height).

RESULTS

Mean age of the 623 women was 56 years. After adjustment for age, body mass index (BMI), physical activity, alcohol consumption, and smoking, the bioavailable testosterone level (p = 0.03) was positively and the SHBG level (p < 0.001) was negatively associated with the logCRP level. The increment in CRP level between the highest and lowest quartile of bioavailable testosterone was 1.28 microg/mL. The increment in CRP level between the lowest and highest quartile of SHBG was 2.62 microg/mL. Compared with SHBG or bioavailable testosterone as predictors of logCRP in separate regression models, when both SHBG and bioavailable testosterone were included in the same multivariate linear regression model, only SHBG remained a statistically significant predictor of logCRP. Progesterone level was positively associated with the logMMP-9 level (p < 0.001); no other sex steroid level was associated with the logMMP-9 level. In multiply adjusted models, no association was found between levels of any sex steroid and IL-6 or sICAM level.

Geriatric syndromes and assessment in older cancer patients

Older individuals are at risk for adverse events in all settings where cancer is treated. Common geriatric syndromes can complicate cancer therapy, and thus, increase patient morbidity and the costs of care. Furthermore, cancer treatment can worsen geriatric syndromes. It is often difficult to determine whether declining health is a result of cancer treatment or the patient's underlying disease. Baseline assessment of multiple factors may facilitate detection of a decline in the patient's health status, which may be remediable. Geriatric syndromes may substantially affect quality of life and are also important in the prognosis and outcome of cancer therapy. This article reviews the assessment of cognitive syndromes (dementia and delirium), vision and hearing impairment, gait and balance difficulties, malnutrition, incontinence, depression, osteoporosis, sleep disorders, environmental and social issues, and functional decline. Although there are many geriatric domains and many focused assessment tools, assessment does not need to be time-consuming. Streamlined assessment tools have been developed; they are brief, inexpensive, and easily administered, and they may be valuable to the oncologist. Staff such as nurses, social workers, or office personnel could perform these assessments and minimize the impact on the physician's time.

Nutritional intake monitoring for nursing home residents: a comparison of staff documentation, direct observation, and photography methods

BACKGROUND

The current approach to assessing nutritional intake requires nursing home (NH) staff to document total percentage of food and fluid consumed at each meal. Because NH staff tend to significantly overestimate total food intake, methods need to be developed to improve the accuracy of food intake measurement.

OBJECTIVE

To compare three methods of assessing the nutritional intake of NH residents.

RESEARCH DESIGN

Validation Study.

SUBJECTS

Fifty-six NH residents in one facility.

MEASURES

Total percentage of food and fluid intake of each resident for each of nine meals, or all three meals for 3 consecutive days, was assessed by: (1) Nursing home staff chart documentation, (2) Research staff documentation according to direct observations, and (3) Research staff documentation according to photographs of residents' trays before and after each meal.

RESULTS

Research staff documentation of total intake and intake of all individual food and fluid items was similar for the direct observation and photography methods. In comparison with these two methods, NH staff documentation reflected a significant overestimate (22%) of residents' total intake levels. In addition, NH staff failed to identify the more than half (53%) of those residents whose intake levels were equal to or below 75% for most meals.

CONCLUSIONS

The photography method of nutritional assessment yielded the same information as direct observations by research staff, and both of these methods showed the intake levels of NH residents to be significantly lower than the intake levels documented by NH staff. The photography method also has several advantages over a documentation system that relies on an observer to be present to record food and fluid intake levels.

Measures of functional status in community-dwelling elders

OBJECTIVE

To evaluate two performance-based measures of functional status and assess their correlation with self-report measures.

DESIGN

Cross-sectional study.

PARTICIPANTS

Of the 363 community-dwelling elders enrolled in a trial of comprehensive geriatric assessment who participated, all had at least one of four target conditions (urinary incontinence, depression, impaired functional status, or history of falling).

MEASUREMENTS

Two performance-based measures, National Institute on Aging (NIA) Battery, and Physical Performance Test (PPT), and three self-report functional status measures, basic and intermediate activities of daily living and the Short-Form-36 (SF-36) physical functioning subscale, were used. Measures of restricted activity days, patient satisfaction and perceived efficacy were also used.

MAIN RESULTS

All measures were internally consistent. There was a high correlation between the NIA and PPT (kappa = 0.71), while correlations between the performance-based and self-report measures ranged from 0.37 to 0.50. When patients with values above the median on the two performance-based measures were compared with those below, there were significant differences (p

CONCLUSIONS

Performance-based measures correlated highly with each other and moderately with questionnaire-based measures. Performance-based measures also had construct validity and did not suffer from floor or ceiling effects.

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Key Words

• performance-based measure
• functional status
• elderly

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MESH Headings

• Aged
• Cross-Sectional Studies
• Geriatric Assessment
• Health Status Indicators
• Humans
• Reproducibility of Results

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Grants

• P60 AG010415 NIA NIH HHS
• 5P60AG10415 NIA NIH HHS

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Affiliation(s)

S E Sherman Multicampus Program in Geriatric Medicine and Gerontology, UCLA School of Medicine, and the Department of Veterans Affairs Medical Center, Sepulveda, Calif 91343, USA
D Reuben

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Cell-based tissue engineering therapies: the influence of whole body physiology

A technology has been developed to isolate a developmentally and phenotypically homogeneous population of pluripotent human mesenchymal stem cells (hMSCs) from adult bone marrow and mitotically expand these cells in culture. These hMSCs have osteoblasts as one of their potential developmental end-stage phenotypes, and, in addition to their osteogenic potential, these hMSCs synthesize and secrete a variety of macromolecules that are known regulators of osteoclast differentiation and activity. In this review, data are presented that demonstrate the phenotypic and developmental homogeneity of the cells in hMSC cultures, as well as their ability to differentiate along multiple phenotypic pathways and serve as regulatory cells for hematopoietic and bone-resorbing cells. In addition, a logic and preliminary data are presented that support the use of hMSCs in the prevention and treatment of age-related and postmenopausal osteoporosis. Since hMSC differentiation and phenotypic expression are controlled by regulatory molecules synthesized and secreted by a variety of local and systemic mechanisms, the issue of whole organism physiology is addressed in considering tissue engineering logics.

Sociodemographic and health factors in driving patterns after 50 years of age

Data from the 1990 Panel Study of Income Dynamics were used to predict, by means of logistic regression, the likelihood that people who had previously driven would continue to drive and to drive after dark after 50 years of age. The results support the conclusion that driving patterns appear to be explained partly by a combination of sociodemographic factors and health status. Furthermore, it is shown that those reported to drive for nondrivers appear to be the same individuals known to provide most informal support for functionally impaired elderly people.

Working group recommendations: targeting criteria for geriatric evaluation and management research

To maximize the cost effectiveness of geriatric evaluation and management (GEM) programs, criteria need to be established for selecting patients most likely to benefit. A working group was convened to define appropriate patient selection (targeting) criteria for each type of GEM program and to consider research questions for future targeting studies. The group outlined targeting criteria for the spectrum of GEM program types and locations. GEM program types included: inpatient GEM units; hospital geriatric consultation service; GEM programs in nursing homes; outpatient GEM programs for functionally impaired persons; and geriatric community outreach/screening programs for functionally independent elders. For each program type, the group outlined targeting criteria based on current literature and experience. Because research has not yet established the effectiveness of many of these patient targeting strategies, the group drafted a set of research questions, pertinent to targeting, that require attention: (1) For each identifiable population of elderly people, who are most likely to benefit from GEM? (2) How should these people best be identified/targeted? (3) What criteria should be used for targeting? (4) How and how often should population screening be performed to identify persons in need of GEM?

Colonic vascular ectasias and aortic stenosis: coincidence or causal relationship?

Eleven patients with vascular ectasias of the colon and associated gastrointestinal hemorrhage were evaluated. All had the clinical features associated with aortic stenosis. In two patients, the configuration of the pulse wave in the mesenteric vessel was studied. In both, the abnormal peripheral pulse wave pattern associated with aortic stenosis was also transmitted to the ileocolic artery, where it differed quite clearly from the pattern in control patients. In a parallel study, the computer records of 3,623 patients with aortic or mitral stenosis admitted to the Mount Sinai Hospital over a 10 year period were reviewed for the presence of cryptogenic gastrointestinal hemorrhage. Twenty-one of 1,811 patients with aortic stenosis but only 1 of 1,812 patients with mitral stenosis had concomitant gastrointestinal hemorrhage (chi-square = 18, p less than 0.001). These data suggest that the cause of colonic vascular ectasias should be attributed to pathologic abnormalities of the arterial inflow pulse wave, rather than to chronic intermittent submucosal venous outflow obstruction.

Diabetes screening using a quantitative urine glucose method

Sensitivity and specificity of three methods (random urine glucose (RUG) &gt; 25 mg. per deciliter; positive Clinitest; and random plasma glucose (RPG) &gt; 140, &gt; 120, and &gt; 100 mg. per deciliter) for detecting the unknown diabetic were compared. In 1,952 screenees, RUG of 96.7 per cent was 3 to 25 mg. per deciliter (normoglucosuria), RUG of 2.0 per cent was 26 to 100 mg. per deciliter (moderate hyperglucosuria), and of 1.3 per cent was &gt; 100 mg. per deciliter (marked hyperglucosuria). Twenty-five randomly selected from each of the first two groups and 18 from the third group had a glucose tolerance test (GTT); seven in the third group had fasting plasma glucose tests &gt; 150 mg. per deciliter. GTTs were evaluated by United States Public Health Service (USPHS), Fajans-Conn (F-C), and summation (S) criteria, and tested screenees divided into nondiabetic (ND) and diabetic (DM). NDs with RUG &gt; 25 mg. per deciliter were false positive screens: renal hyperglucosurics (RHG) if GTT urine glucose ≥ 80 mg. per deciliter, nonrenal hyperglucosurics (NRHG) if GTT urine glucose ≤ 25 mg. per deciliter. The prevalence of DM was 1.24 per cent (USPHS), 1.37 per cent (F-C), and 1.45 per cent (S). The prevalence of false positives (USPHS) was 2.04 per cent (1.19 per cent RHG and 0.85 per cent NRHG). In the normoglucosuria group, 100 per cent who had a GTT were true negatives. In the moderate hyperglucosuria group, 16 per cent (USPHS) were true positives, 84 per cent false positives (44 per cent RHG, 40 per cent NRHG). In the marked hyperglucosuria group, 72 per cent (USPHS) were true positives, 28 per cent false positives (24 per cent RHG and 4 per cent NRHG). By Clinitest, 23 per cent of the DMs (USPHS) were false negatives, and 1.8 per cent in the normoglucosuria group were false positives. Nine per cent of the DMs were false negatives by RPG &gt; 140, and 4.5 per cent were false negatives by RPG &gt; 120.

RUG &gt; 25 mg. per deciliter was as sensitive as the GTT in detecting unknown DMs but was less specific. Random normoglucosuric screenees are unlikely to have diabetes; about 40 per cent of random hyperglucosuric screenees have diabetes.