Engaged communication of environmental health science: Processes and outcomes of urban academic-community partnerships

Those who bear the greatest environmental burdens often have the least access to information, and explanations for engaging communities to develop solutions are lacking. We describe, and use a case study to depict, a participatory process of urban academic and community members to co-produce educational and communication tools. Over five years, we interfaced with 763 individuals at eleven events and three times that (n=2,273) through attendees' networks at 109 small group events using snowball methods. The resulting communication tools, paired resources, and mobile dissemination were responsive to residents' circumstances and enhanced their ability to access health protecting information and resources.

Depression, cognitive impairment and function in Alzheimer's disease

Depression is very common in patients with dementia but the relationship is very complex. Depression is regarded as a cause of excess disability in persons with dementia and contributes to their functional decline. The assessment of depression in dementia patients, however, has been difficult in that the validity of self-reported depression in patients with dementia has been questioned. This study was done to investigate whether self-reported depression by persons with dementia (using the GDS) is related to their functional abilities as rated by a family caregiver (using the IADL scale) above and beyond demographic variables. This study was conducted at the Detroit Satellite of the Michigan Alzheimer's Disease Research Center. There were 141 participants, 67% were African American and 33% were European American. Statistical analyses included a correlational and multiple regression approach to determine the predictive relationships of cognitive and depressive symptoms above and beyond the influence of demographic variables and cognition. The results of the study further support the notion that depression in dementia is significantly related to functional decline but, more importantly, that self-reported depression in patients with dementia can be valuable information in understanding patients' functioning.

The functional performance of elderly urban African-American women who return home to live alone after medical rehabilitation

OBJECTIVE

Elderly women who live alone are at increased risk for loss of independence. Hospitalization, in particular, often marks the transition from independent living to institutional care. The purpose of this study was to examine the relationship of rehabilitation admission to the subsequent function of elderly women and their ability to return to live-alone status.

METHOD

The women in the study (N = 138) were admitted to a geriatric rehabilitation unit at a large urban medical center between September 1997 and September 1998. The findings reported here pertain to the subset of African-American women (n = 122), the majority of the sample. Data were collected using several standardized assessments, including the Functional Independence Measure (FIM).

RESULTS

The FIM motor scores improved significantly for the total sample between admission and discharge, and the mean FIM motor score for the group that subsequently attained live-alone status was significantly higher than the non-live-alone group at 3 months and 6 months postdischarge. The participants who returned to live alone also reported significantly greater independence than did their non-live-alone counterparts across a variety of activities of daily living and instrumental activities of daily living skills.

CONCLUSION

These data suggest that rehabilitation is associated with improved functional outcomes, and higher functional performance is related to live-alone status.

Effective screening for Alzheimer's disease among older African Americans

Relatively little data exist concerning the utility of brief cognitive measures to detect dementia among African Americans. The current study evaluated the clinical utility of the Mini-Mental Status Exam (MMSE) and the Fuld Object Memory Evaluation (FOME) in detecting Alzheimer's disease (AD) among both African American and European American older adults. One hundred and forty geriatric patients from a large urban academic medical center were examined. Overall, the FOME appeared to be more effective in detecting AD than was the MMSE (93% sensitivity vs. 75% sensitivity, respectively), although both measures suffered from relatively low specificity (63.5) in the full sample. The FOME demonstrated exceptional clinical utility among African American patients (sensitivity 98.3%; specificity = 64.5; positive predictive power 83.8%; negative predictive power 95.2%). The results of this study support the use of the FOME among older African Americans to detect dementia.

Environmental press and adaptation to disability in hospitalized live-alone older adults

PURPOSE

This study examined the ability of personal competency variables at the time of hospital discharge to predict primary instrumental activities of daily living (IADLs) and secondary outcomes (living arrangements) in a sample of 194 urban, live-alone, older adults who had a new onset disability.

DESIGN AND METHODS

Consecutively admitted medical rehabilitation patients, 72% women and 85% African American, participated in the study. Using path analysis, three of the four competency variables collected at the time of hospitalization (cognition, medical burden, activities of daily living) predicted IADLs at 3 and 6 months after hospitalization (e.g., cooking, telephone use, money management). IADLs, in turn, predicted living arrangements at 3 and at 6 months after hospitalization.

RESULTS

The findings provided strong support for the importance of assessing a broad range of competency variables when investigating adaptation to disability.

IMPLICATIONS

The increased understanding of adaptation in live-alone older adults with a new-onset disability is particularly timely given the increase in live-alone older adults and the dire consequences associated with change in living arrangement (i.e., mortality and morbidity) in this group.

Expanded normative data for the Mattis Dementia Rating Scale for use with urban, elderly medical patients

Normative data for the Mattis Dementia Rating Scale (MDRS), stratified by age and education, are provided for use with older adults (ages 61-94) in urban medical settings. Age and education accounted for the greatest amount of variance in MDRS performance. Gender and race were also associated with total MDRS scores, though to a lesser extent. The present normative data are more appropriate for use with older patients seen in urban medical settings than normative data obtained from samples of better-educated, relatively healthy, Caucasian adults. This study provides additional evidence of the significant influence of age and education on MDRS total score (MDRS-T) performance, and highlights the importance of matching an examinee's demographic background to the normative sample with which his or her test score is being compared. Careful consideration of this match is likely to lead to more accurate diagnostic conclusions and potentially improved patient care.

Clinical utility of the Normative Studies Research Project test battery among vascular dementia patients

The purpose of the present study was to examine the clinical utility of the Normative Studies Research Project test battery for detecting dementia with a known vascular component. The study compared 65 patients who had both suffered a stroke and met the DSM-IV criteria for dementia with 86 older medical patients who were cognitively intact. Multivariate analysis of covariance results demonstrated that these two groups had significantly different means on tests within the battery even after controlling for the influence of demographic variables. Logistic regression results demonstrated positive predictive value of 81.36%, negative predictive value of 85. 23%, and an overall correct classification rate of 83.67%.

The MacNeill-Lichtenberg Decision Tree: a unique method of triaging mental health problems in older medical rehabilitation patients

OBJECTIVE

Evaluation of the utility of a "decision tree" that identifies potential mental health problems in older medical patients and guides decision making for referrals.

DESIGN

Measures of utility including sensitivity, specificity, and predictive power were examined. Independent t tests and nonparametric statistics were used to evaluate group differences where appropriate.

SETTING

The stroke and geriatric unit of a freestanding urban medical rehabilitation hospital.

SUBJECTS

In study 1,173 older, consecutively admitted medical rehabilitation patients completed all cognitive measures. In study 2, a separate sample of 313 older adults completed the Geriatric Depression Scale during admission.

MAIN OUTCOME MEASURE

The MacNeill-Lichtenberg Decision Tree (MLDT) was compared with the Mini-Mental State Exam (MMSE), the Mattis Dementia Rating Scale, and the 30-item Geriatric Depression Scale.

RESULTS

Study 1: The decision tree accurately triaged 87% of mental health problems and allowed for deferral of 41% of cases, for whom further assessment was unnecessary. The MLDT was superior to the MMSE, with higher sensitivity and a lower failure rate. Study 2: The emotional status component of the MLDT was useful in triaging cases for depression evaluation.

CONCLUSION

The MLDT was useful in prioritizing cases with regard to mental health problems (eg, dementia, depression) and making quick referral decisions. The MLDT is a unique instrument that not only evaluates cognitive status, but also considers psychosocial factors and emotional status in older adults.

Geropsychological problems in medical rehabilitation: dementia and depression among stroke and lower extremity fracture patients

BACKGROUND

Although stroke and lower extremity fracture are often viewed as distinct medical rehabilitation conditions, they share similarities in that they are both experienced primarily among older adults, and are often accompanied by gero-psychological problems such as dementia and depression. In spite of these similarities, actual comparisons of these prevalence rates have been rare in the previous literature, most likely due to obvious differences in the nature of the injuries involved (neurological vs. peripheral injury).

METHODS

One hundred and one stroke and 198 lower extremity fracture patients were assessed with neuropsychological tests from the Normative Studies Research Project test battery. The prevalence rates of dementia and depression were then compared between these two patient groups.

RESULTS

Overall, 34.7% of stroke and 27.8% of lower extremity fracture patients met the criteria for dementia. In addition, 33.3% of stroke and 25.1% of lower extremity fracture patients scored in the depressed range on the Geriatric Depression Scale. The prevalence rates for dementia and depression did not differ significantly between these two patient groups.

CONCLUSIONS

Although rehabilitation efforts focus mainly upon the primary diagnoses of geriatric patients, these findings suggest that stroke and lower extremity fracture should be considered within the context of the geriatric issues (e.g., dementia, depression, and comorbid medical illness) which accompany them.

Cognitive impairment and depression predict mortality in medically ill older adults

BACKGROUND

Depression and cognitive impairment are common in medically ill older adults. Few studies, however, have investigated the roles of both in predicting mortality for medically ill older adults.

METHODS

We used a cohort of consecutive patients aged 60 or older admitted to a rehabilitation hospital (N = 667) of whom 455 completed a standardized protocol measuring cognition (Dementia Rating Scale), depression (Geriatric Depression Scale), and disabilities (Functional Independence Measure). Burden of medical illnesses was measured with the Charlson Index. Vital status was assessed one year later.

RESULTS

Those subjects who did not complete the screening were more likely to die (24% vs 17%; p = .02) during the one-year follow-up. Of those who completed the screening, male sex (odds ratio [OR] = 1.84), depression (mild OR = 1.64; moderate OR = 2.49), and more severe cognitive impairment (OR = 2.13) predicted mortality independent of age, medical illnesses, or disabilities. No interaction of cognitive impairment and depression was detected. In those subjects cognitively intact, moderate depression (OR = 4.95) and male sex (OR = 3.42) were independent risk factors for dying. In those subjects without depression, male sex (OR = 2.24) and elevated Charlson Index (OR = 1.42) predicted mortality.

CONCLUSIONS

Depression and cognitive impairment are independent predictors of one-year mortality in this subgroup of medically ill older adults.

Disease and depression in older medical patients

It was hypothesized that those with systemic diseases such as diabetes mellitus would likely have higher prevalence rates of self-reported depressive symptoms than those diagnosed with nonsystemic diseases in part due to the disability conferred by their diagnosis. Analysis indicated partial support, although, other factors may moderate this relationship.

Standards for psychological services in long-term care facilities

Psychologists in Long-Term Care (PLTC), a national network established in 1983, has developed, with input from colleagues and consumers, standards for psychological practice in long-term care facilities. These standards address provider characteristics, methods of referral, assessment practices, treatment, and ethical issues. This article describes the document's development and offers suggestions for its use.

Morbidity and comorbidity among Great Lakes American Indians: predictors of functional ability

This article explores patterns of morbidity and comorbidity and their ability to predict functional disability among American Indian elders, using data from a sample of urban, rural off-reservation, and reservation Great Lakes American Indians age 55 and older. Higher rates are reported of a number of chronic illnesses than found in overall samples of U.S. elders. Results of multiple regression analyses predicting Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs) show age to be a consistent predictor of functional disabilities: The CMI (Index of Comorbidity) was found to be a more useful predictor of functional disability than was the simple summation of the number of chronic illnesses.

Home alone: the role of cognition in return to independent living

OBJECTIVE

To identify unique predictors of the ability to return to living alone in geriatric patients undergoing medical rehabilitation.

DESIGN

Of 900 consecutive geriatric patients entering medical rehabilitation, 372 were identified as living alone before admission. Data were collected on functional status, cognition, demographics, and discharge disposition.

SETTING

A freestanding medical rehabilitation facility. All patients were admitted to a geriatric rehabilitation unit.

PATIENTS

Patients aged 60 to 99, identified as having lived alone before admission, were included. As standard procedure, patients underwent functional and cognitive assessment, and medical records were reviewed.

MAIN OUTCOME MEASURE

Logistic regression analysis was used to evaluate predictors of discharge disposition, including demographic variables, medical burden, the Functional Independence Measure (FIM), and the Dementia Rating Scale (DRS).

RESULTS

Both the FIM and DRS provided significant and unique variance in prediction of discharge disposition. Patients discharged home alone performed similarly to those discharged with supervision on FIM motor items but higher on FIM social cognition items, emphasizing the strong role of cognition in discharge disposition. Patients discharged home alone scored above suggested cutoff scores on the DRS, indicating generally intact cognitive functioning, whereas those discharged with supervision scored below suggested cutoffs.

CONCLUSION

Results emphasize the importance of cognition in the ability to return to completely independent living after medical rehabilitation in geriatric patients.

Physical, psychological, and social outcomes in geriatric rehabilitation patients

OBJECTIVE

Previous research studies that addressed the relationship between age and functional outcome had limited generalizability because of small sample size, lack of an urban population, and limited variables that do not allow for a complete investigation of social, cognitive, psychological, and medical factors in geriatric rehabilitation. The present study attempted to assess the relationship between decade of geriatric life (60s, 70s, 80s, and 90+) and functional outcome.

DESIGN

Survey study of geriatric cohorts.

SETTING

Inpatient university-affiliated rehabilitation hospital.

PATIENTS

812 urban geriatric rehabilitation patients divided into four groups based on decade of life.

MAIN OUTCOME MEASURES

Index of comorbid disease, principal diagnoses, Functional Independence Measure, Mattis Dementia Rating Scale, Geriatric Depression Scale, CAGE alcohol questionnaire, and residential status at admittance and discharge.

RESULTS

Although there were no significant demographic differences between groups (apart from age), there were differences in functional outcome suggesting that the younger old (60s and 70s) and the older old (80s and 90+) patients may represent two different rehabilitation groups.

CONCLUSIONS

The younger old patients showed significantly higher alcohol abuse and comorbid physical disease, while the older-old patients demonstrated significantly poorer cognitive skills and more dependent social status on discharge from the rehabilitation facility. Despite the younger group's physical problems and alcohol use, they demonstrated better physical recovery. Implications for working with these two groups of urban geriatric patients in a rehabilitation setting are discussed.

An interdisciplinary behavioral treatment program for depressed geriatric rehabilitation inpatients

Depression is known to be associated with increased functional dependence both in the community and in a hospital setting. An innovative interdisciplinary behavioral treatment of depression protocol is described here. Occupational therapists were trained to deliver a protocol of behavioral treatment techniques during their individual occupational therapy treatment sessions. Methods of training the occupational therapists and a description of the treatment are provided in this article. These methods insure that behavioral treatment is delivered accurately and regularly. An outline of each session is provided, and two case examples are described. Early results indicate that this form of treatment can be reliably and accurately carried out.

The relationship between depression and cognition in older adults: a cross-validation study

The relationship between depression and cognition in older adults has become a topic of extensive research and clinical interest. Results of previous research are limited, however, by sampling and methodological problems. Small sample sizes and the treatment of depression as a dichotomous variable may be major factors that limit data interpretation in previous studies. The present sample of 220 geriatric medical patients was split into a validation and a cross-validation sample specifically to test the hypothesis that depression is an independent predictor of cognition. Multiple regression analyses, controlling for the direct effects of demographic factors, found that Geriatric Depression Scale scores were consistently a significant predictor of Dementia Rating Scale and Logical Memory scores. Overall, GDS scores accounted for approximately 8% of unique variance for both measures of cognition. Demographic factors, particularly age and race, were also significant predictors of cognitive test scores. These data were interpreted as providing support for the hypothesis that level of depression predicts level of cognitive functioning.

Predicting bowel and bladder continence from cognitive status in geriatric rehabilitation patients

Incontinence in an elderly person is frequently an important factor in deciding whether to institutionalize the patient. This study examined the association between cognition and continence in geriatric patients admitted to an inpatient rehabilitation unit. It was hypothesized that admission cognitive status would help predict discharge bowel and bladder continence and would account for significant unique variance beyond that explained by admission continence status. The Dementia Rating Scale (DRS) was administered to 103 consecutive subjects admitted to a geriatric rehabilitation unit. Admission and discharge bowel and bladder status ratings were made using the Functional Independence Measure. Multiple stepwise regression analysis found admission incontinence status coupled with the DRS Initiation/Preservation (IP) subtest significantly predicted bowel and bladder management status at discharge. The IP subtest accounted for a significant but modest amount of unique variance beyond the admission continence status.

Extended normative data for the Logical Memory subtests of the Wechsler Memory Scale--Revised: responses from a sample of cognitively intact elderly medical patients

66 cognitively intact geriatric medical patients (ages 70 to 99; M = 77 yr.) were given the Logical Memory subtests of the Wechsler Memory Scale--Revised to extend normative data. 43 women and 23 men, 35 white and 31 black persons made up this urban geriatric sample. A review of patients' medical histories and Mattis' Dementia Rating scores of 129 or greater were used to ensure a sample of cognitively intact patients. Analyses showed that Logical Memory scores were uncorrelated with education, race, sex, or age.

Comparison of the Hamilton Depression Rating Scale and the Geriatric Depression Scale: detection of depression in dementia patients

The present longitudinal prospective study compared results from the Geriatric Depression Scale with those from the Hamilton Depression Rating Scale for 30 dementia patients. The criterion measure was presence of depression as indicated by the psychiatric diagnosis. The psychiatrist and physician's assistant made the Hamilton ratings while the psychology staff administered the Geriatric Depression Scale. The two measures were statistically unrelated from Times 1 and 2 (rs = .26 and .41). Eleven (37%) patients were depressed and nine received antidepressant medications. Sensitivity ratings were 82% and 9%, respectively, and specificity ratings were 88% and 92%, respectively. Possible explanations for the success of the Geriatric Depression Scale and lack of success of the Hamilton ratings in detecting depression in this population are discussed.

Outpatient psychogeriatric nursing services: an integrative model

The complex needs of psychogeriatric patients and their families require specialized outpatient psychogeriatric services. The interaction of physical and mental health and the need for coordinated care places important responsibilities on nursing because it contributes to integrated, multidisciplinary care delivery to these patients and their families. This article presents a model of outpatient psychogeriatric nursing services focused on the community integration of patients and families. Experiences in the development of the Geriatric Neuropsychiatry Clinic at the University of Virginia, Charlottesville, are used as the point of departure from which to describe a model of outpatient psychogeriatric nursing care delivery that is multidisciplinary, clinically innovative, and epidemiologically justified.

Assessments of institutionalized dementia patients' competencies to participate in intimate relationships

Although sexual interests in institutionalized elderly patients have long been recognized (Comfort, 1974; Wasow & Loeb, 1974), guidelines to help determine patients' competencies to participate in intimate relationships are not delineated in the literature. This paper describes the assessment technique used by an interdisciplinary staff on a coed Alzheimer's disease unit. Two case studies are presented to highlight how the assessment led to the treatment decisions.

Further investigation of the role of personality, lifestyle and arthritic severity in predicting pain

Lichtenberg et al. (1984) presented empirical research on elderly osteoarthritics that indicated that personality, specifically hypochondriasis, was the most powerful predictor of pain as compared with arthritic severity and recent life stress. This study investigated further the role of psychological predictors and arthritic severity ratings in accounting for perceived pain. The study included 70 subjects with an average age of 68 years. The results indicated that hypochondriasis was the predictor most highly related to pain. Arthritic severity ratings and other psychological predictors were also significantly related to pain. In a multiple regression analysis arthritic severity predicted 13 percent of pain variance whereas the psychological predictors accounted for an additional 41 percent of the variance. Age of the individual was related to several psychological variables. New possibilities for therapeutic intervention are discussed.

The role of personality, recent life stress and arthritic severity in predicting pain

This study investigated the role of personality, life stress and osteoarthritic severity in accounting for pain in aged individuals. Previous empirical research on older adults with chronic pain is nonexistent. The study included 40 subjects with an average age of 70 yr. Results indicated that personality, specifically hypochrondriasis of the individual, was the most powerful predictor of pain as compared with arthritic severity and life stress. Subjective pain was lower among older patients than among younger patients despite greater arthritic severity. The amount of hypochondriasis and life stress was also less for older patients. Implications for interventions in terms of modifying perception of pain in older adults is discussed.