Cognition and Perceived Social Support Among Live-Alone Urban Elders

The relationship of cognition to perceived social support (PSS) was examined in a sample of 188 older medical patients who lived alone before admission to the hospital. Most of the patients were African American, and a majority (54.3%) was classified as cognitively impaired based on their performance on the Mattis Dementia Rating Scale. Compared with cognitively intact elders, impaired participants reported lower overall PSS as well as lower PSS in their relationships with friends and significant others. These findings suggest that cognitive functioning is an important factor in influencing older, medically ill African Americans'perceived social support. Possible risk factors for low PSS and the role of cognition in friendship and maintenance of a social support network are discussed.

Elderly Inner City Women Who Return Home to Live Alone

This study examined the status of 107 elderly inner city women who returned to their home after being in a geriatric rehabilitation unit at a large urban medical center. Prior to admission, all women had been living at home alone. After rehabilitation, 50 of the women were discharged directly to their homes, 26 followed within 3 months, 11 were back home alone by 6 months, and 20 additional women were still not home by 6 months. Results showed that, as measured by standardized assessments of physical functioning and cognition, the women who were most functionally independent returned home alone more quickly. Furthermore, those who achieved live-alone status some time after discharge (but not at discharge) did not report the same level of self-care and home maintenance task independence as women who were discharged home alone immediately at discharge. The findings raise questions about the minimum level of functional performance required to return home alone and the interaction of functional ability, assistance from others, and a variety of social and environmental factors on live-alone status.

“Vascular Depression” Predicts Verbal Fluency in Older Adults

Past research has found links among cerebrovascular risk factors (CVRFs), depression, and cognition in older adults. This study investigated how well baseline cerebrovascular burden and depression predicted verbal fluency three and six months later. Participants were 139 medical rehabilitation patients, age 60 and above. The Geriatric Depression Scale, Charlson Co-Morbidity Index, and Dementia Rating Scale were administered at baseline, and verbal fluency was measured three and six months later. Structural equation modeling found that depression significantly predicted verbal fluency at both time points, independently of demographic variables, baseline cognition, or medical burden. CVRFs correlated with depressive symptoms but did not independently predict verbal fluency. Findings suggest that vascular depression may be a possible signal of impaired brain integrity, consistent with Alexopoulos and colleague's (2000) conceptual framework.

Risk Factors for Geriatric Depression: The Importance of Executive Functioning Within the Vascular Depression Hypothesis

BACKGROUND

Results from recent studies addressing the vascular depression hypothesis have been mixed, with cerebrovascular risk factors (CVRFs) predicting depression in some geriatric patients but not in others. The current study seeks to examine executive dysfunction as a potential moderator of the relationship between CVRFs and depressive symptoms.

METHODS

Data concerning CVRFs, executive functioning, and depressive symptoms from 77 geriatric rehabilitation patients were incorporated to test the hypothesis that patients with executive dysfunction and greater CVRFs would demonstrate the highest levels of depression over time. CVRFs (diabetes, hypertension, atrial fibrillation) were measured via diagnosis by treating physician. Depression was assessed using the 15-item Geriatric Depression Scale (GDS) at baseline and at 6-month and 18-month follow-ups. Executive functioning was measured at baseline using the Initiation/Perseveration (IP) Subtest of the Mattis Dementia Rating Scale.

RESULTS

Multivariate analysis of variance demonstrated a significant statistical interaction between the number of CVRFs and scores on the IP Subtest on depressive symptoms. Patients with two or more CVRFs and lower IP scores demonstrated significantly greater depressive symptoms at baseline and at 18-month follow-up than patients with fewer CVRFs and higher IP scores. The univariate effect at 6 months was not significant.

CONCLUSION

The current data suggest that scores on an index of executive functioning may moderate the relationship between CVRFs and depressive symptoms. Interpretation of these findings is provided in the context of the vascular depression hypothesis and related frontostriatal dysfunction. Patients with greater CVRF burden and poor executive functioning may be at particularly high risk for depression.

Post-stroke and clinically-defined vascular depression in geriatric rehabilitation patients

OBJECTIVE

The authors examined the vascular depression hypothesis by comparing the frequency of post-stroke depression and clinically-defined vascular depression and by examining the relationship between vascular burden and depression.

METHODS

Data from 670 geriatric rehabilitation patients were incorporated to compare the frequency of depression in three patient groups: 1) those with no evidence of vascular disease or stroke, 2) those with cerebrovascular risk factors (CVRFs) but no evidence of stroke, and 3) patients with stroke. They examined the unique relationship between CVRFs and depression by use of logistic-regression analysis.

RESULTS

Although the frequency of depression was not significantly different between stroke (36.4%), CVRF (35.2%), and non-vascular patients (28.7%), there was a significant increase in the frequency of depression in patients without stroke as CVRF burden increased. This effect was not observed among stroke patients. CVRF burden predicted depression among patients without stroke even after controlling for general medical comorbidity, cognitive functioning, and ADL limitations.

CONCLUSIONS

These findings provide empirical support for the vascular depression hypothesis and also indicate that the rates of clinically-defined vascular depression and post-stroke depression are similar in geriatric rehabilitation patients.

Longitudinal support for the relationship between vascular risk factors and late-life depressive symptoms

OBJECTIVE

The authors examined longitudinal support for the vascular depression hypothesis by assessing the extent to which baseline vascular burden was associated with depressive symptoms 6 and 18 months after discharge from inpatient medical rehabilitation.

METHODS

One hundred consecutive geriatric rehabilitation patients were assessed during their rehabilitation stay and subsequently screened for depression 6 and 18 months after discharge. Baseline vascular burden was entered into logistic-regression analyses predicting depression at 6 and 18 months after controlling for baseline levels of depression, general medical burden, limitations in activities of daily living, cognitive impairment, and demographic variables including age, education, gender, and race.

RESULTS

Logistic-regression results demonstrated that, after controlling for the covariates described above, baseline vascular burden was associated with increased odds of positive depression screens at 6- and 18-month follow-up assessments. Furthermore, among patients who were not depressed during their rehabilitation stay, vascular burden was predictive of positive depression screens at 6- and 18-month follow-up assessments.

CONCLUSIONS

Greater vascular burden was positively associated with depressive symptoms over time. These findings provide further support for the vascular depression hypothesis in late life and highlight the need for careful clinical monitoring of this frail group of elderly patients.

After rehabilitation: an 18-month follow-up of elderly inner-city women

OBJECTIVE

Elderly inner-city women (n = 125) greater than the age of 60 and living alone and who were consecutively admitted to a large, urban, university-based rehabilitation hospital were followed to (a) examine the power of standardized clinical measures to predict who was living alone 18 months after discharge, (b) determine whether live-alone women at 18 months' follow-up were more independent in instrumental activities of daily living (IADL) than women who were not living alone, and (c) investigate whether women who return home to live alone and have low or declining physical function are at risk for subsequent relocation or death.

METHOD

Data from four standardized assessments (physical function, cognition, comorbidity, and depression) and demographic information were gathered during in-patient rehabilitation. Self-report IADL data were collected via telephone interviews at 3, 6, and 18 months' follow-up.

RESULTS

Statistical analysis of results showed that physical function, cognition, and comorbidity were significant and independent predictors of living alone at 18 months' follow-up. Women living alone at 18 months reported significantly greater IADL independence than women who were not living alone. Path analysis confirmed that the relationship between the clinical measures and living situation at 18 months was mediated by self-reported IADL functioning.

CONCLUSION

Standard clinical data obtained at discharge are useful to identify who can return home to live alone after rehabilitation, but in-home assessment of IADL remains key to understanding the complex skills required to live alone.

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.

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.

Psychosocial factors related to unrecognized acute myocardial infarction

Acute myocardial infarction (AMI) often is unrecognized (i.e., a patient fails to notice or report the event to the physician, or the physician fails to diagnose it). Psychosocial differences between patients with recognized and unrecognized AMI have not been examined. We compared 40 patients who sought treatment for a documented AMI with 30 patients who were found on routine electrocardiogram to have had an AMI for which they did not seek medical care. Patients with unrecognized AMI showed greater "alexithymia," or deficient psychologic awareness (p = 0.04; Alexithymia Provoked Response Interview), and a greater belief that chance factors determine their health (p = 0.004; Multidimensional Health Locus of Control Scale). Patients with unrecognized AMI were less likely to have angina, yet did not differ from those with recognized AMI with regard to demographics, smoking, systemic hypertension, diabetes mellitus, AMI location, depression, or hypochondriasis. We hypothesize that deficient psychologic awareness may impede AMI symptom perception or recognition, and that the belief in chance or fate as determining health may inhibit treatment-seeking.