Assessing the Progression of Alzheimer's Disease in Real-World Settings in Three European Countries.

BACKGROUND: There exists considerable variation in disease progression rates among patients with Alzheimer's disease (AD). OBJECTIVE: The primary objective of this observational study is to assess the progression of AD by characterizing cognitive, functional, and behavioral changes during the follow-up period between 6 and 24 months. METHODS: A longitudinal prospective study with community-dwelling patients with an established clinical diagnosis of AD of mild to moderate severity was conducted in Germany, Spain and the UK. A sample of 616 patients from 69 sites was included. RESULTS: Patients had a mean of 1.9 years (SD = 1.9) since AD diagnosis at study inclusion. Cognitive symptoms were reported to have first occurred a mean of 1.1 years (SD = 1.7) prior to AD diagnosis and 1.4 (SD = 1.8) years prior to AD treatment. Patients initially diagnosed with mild and moderate AD spent a median (95%CI) of 3.7 (2.8; 4.4) and 11.1 (6.1, 'not reached') years until progression to moderate and severe AD, respectively, according to the Mini-Mental State Examination (MMSE) scores. A mixed model developed for cognitive, functional, and neuropsychiatric scores, obtained from study patients at baseline and during follow-up period, showed progressive deterioration of AD patients over time. CONCLUSION: The study showed a deterioration of cognitive, functional, and neuropsychiatric functions during the follow-up period. Cognitive deterioration was slightly faster in patients with moderate AD compared to mild AD. The duration of moderate AD can be overestimated due to the use of retrospective data, lack of availability of MMSE scores in clinical charts and exclusion of patients at time of institutionalization.

Experiences of parents with an adolescent abusing substances admitted to a mental health institution in Giyani, South Africa.

BACKGROUND: Substance abuse by adolescents may be a problem that contributes to their mental illness. Substance abuse does affect not only the individual who is abusing it but also friends, family and the whole community. The adolescent abusing substances may be mentally unstable and have unpredictable behaviour. There is no research on the experiences of parents with adolescents abusing substances in Giyani, South Africa. OBJECTIVE: The purpose of the study was to explore and describe the experiences of parents with adolescents abusing substances admitted to a mental health institution in Giyani. METHOD: A qualitative, exploratory, descriptive and contextual research design was used. Data were collected by means of conducting individual, in-depth, phenomenological interviews, observations and field notes. The following central question was asked to the participants: 'How is it for you to have an adolescent who is abusing substances'. Data were analysed by using a thematic method of coding. An independent coder analysed data together with the researcher, and consensus was reached. RESULTS: Four themes emerged from the data: parents experienced uncontrolled thoughts regarding their adolescent abusing substances, not being able to control their adolescent abusing substances through discipline, negative feelings regarding their adolescent abusing substances and negative consequences regarding their adolescents abusing substances. CONCLUSION: From the study result, it is clear that parents with adolescent abusing substances need professional assistance and support as evidenced by the challenges faced in terms of promoting, maintaining and restoring their mental health. Psychiatric nurses should take responsibility to educate the community about substance abuse, for example offering school health programmes. Further research studies can also be conducted in other villages to gain a greater understanding of those parents' experiences with an adolescent abusing substances.

Depression and Cognitive Impairment in Institutionalized Older Adults.

BACKGROUND: In the last three decades, the relationship between depression and cognition in geriatric patients has been a popular topic among researchers and clinicians. Clinical and epidemiological research has focused on the identification of risk factors that could be modified in pre-dementia syndromes, at a preclinical and early clinical stage of dementia disorders, with specific attention to the role of depression. The objective of this work was to determine the relationship between depressive disorder and cognitive deterioration in institutionalized older adults. METHODS: In this descriptive, correlational study, data were gathered from two nursing homes in the province of Jaen (Spain), from a random sample of 140 older adults (70 nondependent and 70 dependent). The variables were measured using comprehensive geriatric assessment, the Cambridge Cognitive Test (CAMCOG), and the Geriatric Depression Scale (GDS). RESULTS: Depression was correlated with cognitive level in the nondependent older adult sample (r = -0.471, p = 0.004). Age was inversely associated with the score obtained in the CAMCOG of the nondependent older adult sample (r = -0.352, p = 0.038). The functional capacity in several activities of daily living was correlated with the score obtained in the CAMCOG in each of the two groups. Depression was more prevalent in the dependent than in the nondependent older adults (82.85 vs. 57.14%). No association was observed between institutionalization time and the score obtained on the cognitive and affective scales (GDS and CAMCOG) in both groups (GDS-nondependent, r = -0.209, p = 0.234; CAMCOG-nondependent, r = 0.007, p = 0.967; GDS-dependent, r = 0.251, p = 0.152; CAMCOG-dependent, r = -0.021, p = 0.907). CONCLUSION: Depressive symptomatology is associated with cognitive deterioration. Depression is prevalent in institutions that care for older, more dependent adults.

Combination of 3-Dimensional Virtual Reality and Hands-On Aromatherapy in Improving Institutionalized Older Adults' Psychological Health: Quasi-Experimental Study.

BACKGROUND: In Taiwan, which has one of the most rapidly aging populations in the world, it is becoming increasingly critical to promote successful aging strategies that are effective, easily usable, and acceptable to institutionalized older adults. Although many practitioners and professionals have explored aromatherapy and identified its psychological benefits, the effectiveness of combining 3-dimensional (3D) virtual reality and hands-on aromatherapy remains unknown. OBJECTIVE: A quasi-experimental trial was designed to evaluate the effectiveness of this combination in lowering perceived stress and promoting happiness, sleep quality, meditation experience, and life satisfaction among institutionalized older adults in Taiwan. METHODS: A total of 60 institutionalized elderly participants either received the combined intervention or were in a control group. Weekly 2-hour sessions were implemented over 9 weeks. The outcome variables were happiness, perceived stress, sleep quality, meditation experience, and life satisfaction, which were assessed at baseline and after the intervention. RESULTS: Generalized estimating equation (GEE) analyses indicated that the experimental group showed significant post-intervention improvements in terms of scores for happiness, perceived stress, sleep quality, meditation experience, and life satisfaction (n=48; all P<.001). Another GEE analysis showed that the significant improvements in the 5 outcome variables persisted in participants aged 80 years and older (n=35; all P<.001). CONCLUSIONS: This is the first trial to explore the effectiveness of a combination of 3D virtual reality and hands-on aromatherapy in improving older adults' psychological health. The results are promising for the promotion of psychological health in institutionalized older adults. TRIAL REGISTRATION: ClinicalTrials.gov NCT04324216; https://clinicaltrials.gov/ct2/show/NCT04324216.

Quality of life of institutionalized aged with and without symptoms of depression.

OBJECTIVE: compare the quality of life (QOL) of aged residents in homes for aged people with or without symptoms of depression, and identify social, physical activity; leisure; health and basic activities of daily living (ADL) variables that correlate with QOL scores. METHOD: cross-sectional study conducted with 101 institutionalized aged. Multiple linear regression was used for data analysis. RESULTS: symptoms of depression changed negatively the QOL in the domains: autonomy; present, past and future activities; social participation; intimacy and total score. Dependent aged presented lower QOL for the performance of ADL in the domains: autonomy; social participation and total score; dancing without limitation of movement; liking the residential and not presenting symptoms of depression were the variables that positively influenced the QOL of the aged. CONCLUSION: social and psychological support, good living conditions and stimulating assistance can improve the QOL of institutionalized elderlies.

Multimodal prehabilitation to reduce the incidence of delirium and other adverse events in elderly patients undergoing elective major abdominal surgery: An uncontrolled before-and-after study.

BACKGROUND: Delirium is a common and serious complication in elderly patients undergoing major abdominal surgery, with significant adverse outcomes. Successful strategies or therapies to reduce the incidence of delirium are scarce. The objective of this study was to assess the role of prehabilitation in reducing the incidence of delirium in elderly patients. METHODS: A single-center uncontrolled before-and-after study was conducted, including patients aged 70 years or older who underwent elective abdominal surgery for colorectal carcinoma or an abdominal aortic aneurysm between January 2013 and October 2015 (control group) and between November 2015 and June 2018 (prehabilitation group). The prehabilitation group received interventions to improve patients' physical health, nutritional status, factors of frailty and preoperative anaemia prior to surgery. The primary outcome was incidence of delirium, diagnosed with the DSM-V criteria or the confusion assessment method. Secondary outcomes were additional complications, length of stay, unplanned ICU admission, length of ICU stay, readmission rate, institutionalization, and in-hospital or 30-day mortality. RESULT: A total of 360 control patients and 267 prehabilitation patients were included in the final analysis. The mean number of prehabilitation days was 39 days. The prehabilitation group had a higher burden of comorbidities and was more physically and visually impaired at baseline. At adjusted logistic regression analysis, delirium incidence was reduced significantly from 11.7 to 8.2% (OR 0.56; 95% CI 0.32-0.98; P = 0.043). No statistically significant effects were seen on secondary outcomes. CONCLUSION: Current prehabilitation program is feasible and safe, and can reduce delirium incidence in elderly patients undergoing elective major abdominal surgery. This program merits further evaluation. TRIAL REGISTRATION: Dutch Trial Registration, NTR5932.

Analysis of Functional and Cognitive Impairment in Institutionalized Individuals with Movement Disorders.

BACKGROUND: Many neurological disorders lead to institutionalization and can be accompanied in their advanced stages by functional impairment, and progressive loss of mobility, and cognitive alterations. OBJECTIVE: We analyzed the relationship between functional impairment and cognitive performance and its related subdomains in individuals with Parkinson's disease, Alzheimer's disease accompanied by motor dysfunction, and with other neurological disorders characterized by both motor and cognitive problems. METHODS: All participants lived in nursing homes (Valencia, Spain) and underwent cognitive evaluation with the Mini-Mental State Examination; functional assessment of independence in activities of daily living using the Barthel score and Katz index; and assessment of mobility with the elderly mobility scale. RESULTS: The mean age of the subjects was 82.8 ± 0.6 years, 47% of the sample included individuals with Parkinson's disease, and 48 % of the sample presented severe cognitive impairment. Direct significant relationships were found between the level of cognitive impairment and functional capacity (p < 0.01) and mobility (p < 0.05). Among the different domains, memory impairment was not associated with altered activities of daily living or mobility. The functional impairment and the risk of severe cognitive impairment were significantly (p<0.05) higher in female compared to male patients. Among comorbidities, overweight/obesity and diabetes were significantly (p < 0.05) associated with poor cognitive performance in those individuals with mild/moderate cognitive impairment. CONCLUSION: In institutionalized individuals with movement disorders there is an association between functional and cognitive impairment. Reduction of over-weight and proper control of diabetes may represent novel targets for improving cognitive function at such early stages.

Association of Antidementia Therapies With Time to Skilled Nursing Facility Admission and Cardiovascular Events Among Elderly Adults With Alzheimer Disease.

Importance: To date, no study has compared time to skilled nursing facility (SNF) admission and cardiovascular events across medications available to treat Alzheimer disease. Objective: To compare time to SNF admission and cardiovascular events between acetylcholinesterase inhibitor (AChEI) monotherapy, memantine hydrochloride monotherapy, and combination therapy with an AChEI and memantine in treating elderly adults with Alzheimer disease. Design, Setting, and Participants: This retrospective cohort study uses January 1, 2006, to December 31, 2014, claims data from a 5% random sample of Medicare beneficiaries who had received a new diagnosis of Alzheimer disease between January 1, 2007, and December 31, 2013, and who initiated AChEI monotherapy, memantine monotherapy, or combination therapy with an AChEI and memantine (N = 73 475). Patients were followed up until discontinuation of treatment, switch of treatment, death, or the end of the study period. Statistical analysis was conducted from February 15, 2018, to June 15, 2018. Exposures: Acetylcholinesterase inhibitor monotherapy (n = 44 424), memantine monotherapy (n = 11 809), and combination therapy with an AChEI and memantine (n = 17 242). Main Outcomes and Measures: Primary outcomes were time to SNF admission and the composite of the following cardiovascular events: acute myocardial infarction, bradycardia, syncope, atrioventricular block, QT interval prolongation, and ventricular tachycardia. Cox proportional hazards regression models were constructed to compare outcomes between each pair of treatment groups, controlling for a comprehensive list of patient characteristics. Results: The study population included 73 475 participants (53 068 women and 20 407 men; mean [SD] age, 81.8 [8.3] years); 25.5% of the participants initiating AChEI monotherapy, 25.6% of participants initiating memantine monotherapy, and 29.7% of participants initiating combination therapy with an AChEI and memantine were admitted to an SNF. Similarly, 22.2% of the participants initiating AChEI monotherapy, 20.0% of those initiating memantine monotherapy, and 24.5% of those initiating combination therapy experienced at least 1 cardiovascular event. No difference in time to SNF admission was found across the 3 treatment groups. The risk of the composite measure of any cardiovascular event did not differ between the combination therapy and AChEI monotherapy groups (adjusted hazard ratio [aHR], 0.99; 95% CI, 0.96-1.03); however, it was higher for both AChEI monotherapy (aHR, 1.07; 95% CI, 1.02-1.12) and combination therapy (aHR, 1.07; 95% CI, 1.01-1.12), relative to memantine monotherapy. This result was mainly driven by the lower risk of bradycardia and syncope observed for the memantine monotherapy group relative to both AChEI monotherapy (bradycardia: aHR, 0.88; 95% CI, 0.82-0.95; and syncope: aHR, 0.92; 95% CI, 0.86-0.97) and combination therapy (bradycardia: aHR, 0.89; 95% CI, 0.82-0.97; and syncope: aHR, 0.87; 95% CI, 0.83-0.94). Conclusions and Relevance: Time to SNF admission did not differ across treatment groups, but memantine monotherapy was associated with a lower risk of cardiovascular events compared with both AChEI monotherapy and combination therapy with an AChEI and memantine.

What drives changes in institutionalised mental health care? A qualitative study of the perspectives of professional experts.

BACKGROUND: Since 1990, the provision of mental healthcare has changed substantially across Western Europe. There are fewer psychiatric hospital beds and more places in forensic psychiatric hospitals and residential facilities. However, little research has investigated the drivers behind these changes. This study explored qualitatively the perspectives of mental health professional experts on what has driven the changes in Western Europe. METHODS: In-depth interviews were conducted with twenty-four mental health experts in England, Germany and Italy, who as professionals had personal experiences of the changes in their country. Interviewees were asked about drivers of changes in institutionalised mental health care from 1990 to 2010. The accounts were subjected to a thematic analysis. RESULTS: Four broad themes were revealed: the overall philosophy of de-institutionalisation, with the aim to overcome old-fashioned asylum style care; finances, with a pressure to limit expenditure and an interest of provider organisations to increase income; limitations of community mental health care in which most severely ill patients may be neglected; and emphasis on risk containment so that patients posing a risk may be cared for in institutions. Whilst all themes were mentioned in all three countries, there were also differences in emphasis and detail. CONCLUSIONS: Distinct factors appear to have influenced changes in mental health care. Their precise influence may vary from country to country, and they have to be considered in the context of each country. The drivers may be influenced by professional groups to some extent, but also depend on the overall interest and attitudes in the society at large.

Adding insult to brain injury: young adults' experiences of residing in nursing homes following acquired brain injury.

PURPOSE: There is general consensus that adults under age 65 with acquired brain injury residing in nursing homes is inappropriate, however there is a limited evidence base on the issue. Previous research has relied heavily on third-party informants and qualitative studies have been of questionable methodological quality, with no known study adopting a phenomenological approach. This study explored the lived experiences of young adults with brain injury residing in aged care facilities. METHODS: Interpretative phenomenological analysis was employed to collect and analyze data from six semi-structured interviews with participants regarding their experiences of living in nursing homes. RESULTS: Two themes were identified, including "Corporeal prison of acquired brain injury: broken selves" and "Existential prison of the nursing home: stagnated lives". Results illustrated that young adults with acquired brain injury can experience aged care as an existential prison in which their lives feel at a standstill. This experience was characterized by feelings of not belonging in a terminal environment, confinement, disempowerment, emptiness and hope for greater autonomy through rehabilitation. CONCLUSION: It is hoped that this study will provide relevant professionals, services and policy-makers with insight into the challenges and needs of young adults with brain injury facing these circumstances. Implications for rehabilitation This study supports the contention that more home-like and age-appropriate residential rehabilitation services for young adults with acquired brain injury are needed. As development of alternative accommodation is a lengthy process, the study findings suggest that the interim implementation of rehabilitative care in nursing homes should be considered. Taken together with existing research, it is proposed that nursing home staff may require training to deliver evidence-based rehabilitative interventions to those with brain injury. The present findings add support to the call for systemic change in Ireland, to clarify the acquired brain injury care pathway and establish integrated rehabilitation services.

Quality of life of institutionalized aged with and without symptoms of depression / Calidad de vida de los ancianos institucionalizados con y sin síntomas de depresión / Qualidade de vida de idosos institucionalizados com e sem sinais de depressão

ABSTRACT Objective: compare the quality of life (QOL) of aged residents in homes for aged people with or without symptoms of depression, and identify social, physical activity; leisure; health and basic activities of daily living (ADL) variables that correlate with QOL scores. Method: cross-sectional study conducted with 101 institutionalized aged. Multiple linear regression was used for data analysis. Results: symptoms of depression changed negatively the QOL in the domains: autonomy; present, past and future activities; social participation; intimacy and total score. Dependent aged presented lower QOL for the performance of ADL in the domains: autonomy; social participation and total score; dancing without limitation of movement; liking the residential and not presenting symptoms of depression were the variables that positively influenced the QOL of the aged. Conclusion: social and psychological support, good living conditions and stimulating assistance can improve the QOL of institutionalized elderlies.

RESUMEN Objetivo: comparar la calidad de vida (CV) de los ancianos residentes en instituciones de larga permanencia con o sin síntomas de depresión, e identificar variables sociales, de actividad física, de ocio, de salud y de actividades básicas de la vida diaria (ABVD) que se correlacionan con las puntuaciones de CV. Método: estudio transversal realizado con 101 ancianos institucionalizados. Para el análisis de los datos se utilizó la regresión lineal múltiple. Resultados: los síntomas de depresión cambiaron negativamente la CV en los dominios: autonomía; actividades presentes, pasadas y futuras; participación social; intimidad y puntuación total. Los ancianos dependientes para la realización de la ABVD tuvieron menor CV en los dominios: autonomía, participación social y puntuación total; bailar sin limitación de movimiento, gustar de lo hogar, y no mostrar síntomas de depresión, fueron las variables que influenciaron de forma positiva en la CV de los ancianos. Conclusión: el apoyo social y psicológico, unas buenas condiciones de vida y una asistencia estimulante pueden mejorar la calidad de vida de los ancianos institucionalizados.

RESUMO Objetivo: comparar a qualidade de vida (QV) de idosos residentes em instituições de longa permanência com ou sem sinais de depressão, e identificar variáveis sociais, de atividade física, lazer, saúde e atividades básicas da vida diária (ABVD) que se correlacionam aos escores de QV. Método: estudo transversal realizado com 101 idosos institucionalizados. A regressão linear múltipla foi usada para a análise dos dados. Resultados: sinais de depressão alteraram negativamente a QV nos domínios: autonomia, atividades presentes, passadas e futuras, participação social, intimidade e escore total; idosos dependentes para a realização das ABVD apresentaram QV inferior nos domínios: autonomia, participação social e escore total; dançar sem limitação de movimento, gostar do residencial e não apresentar sinais de depressão foram as variáveis que influenciaram positivamente a QV dos idosos. Conclusão: suporte social e psicológico, boas condições de moradia e assistência estimuladora podem melhorar a QV de idosos institucionalizados.

Factors Associated with the Caregivers' Desire to Institutionalize Persons with Dementia: A Cross-Sectional Study.

BACKGROUND/AIMS: Dementia is one of the main reasons for institutionalization among the elderly. Few studies have explored factors associated with the caregivers' (CG) desire to institutionalize (DTI) a person with dementia (PWD). The objective of this study is to identify modifiable and non-modifiable psychosocial and sociodemographic factors associated with a caregiver's DTI. METHODS: Cross-sectional data of 355 informal CG of community-dwelling PWD were analyzed. Several characteristics were identified in CG and PWD to be included in a multivariable regression model based on the purposeful selection method. RESULTS: Positively modifiable associated factors were: higher CG burden, being affected by behavioral problems, and respite care use. Positively associated non-modifiable factors were: CG older age, being professionally active, and CG higher educational level. Cohabitation and change of professional situation were negatively associated. CONCLUSION: Although no causality can be assumed, several practical recommendations can be suggested. First of all, these results reconfirm the importance of multicomponent strategies, especially support aimed at decreasing burden and in learning coping strategies. Also, CG might benefit from information about support options, such as respite care services. Finally, special attention should be given to older and working CG. In the latter, flexible and adaptive working conditions might alleviate burden and therefore reduce the DTI of the PWD.

Pregnancy in women with psychotic disorders: risk factors associated with mother-baby separation.

Pregnancy in women suffering from psychotic disorders is becoming more common. However, this psychiatric disorder is linked to the highest risk of early mother and child separation. The aim of this study was to evaluate risk factors associated with these separations. In an observational, naturalist, and multicentric study, 320 women suffering from a psychotic disorder and jointly hospitalized with their child in one of the sixteen mother-baby units (MBUs) in France and Belgium between 2001 and 2010 were assessed for risk factors associated with mother-child separation. Eighty-seven (27.2%) mothers were separated from their infant at discharge from MBUs. Early separation was linked to the placement of the mother herself in an institution in childhood (OR 4.44; CI 95% 1.12-18.69), to the mother being single (OR 3.84; CI 95% 1.38-11.44), to early hospitalization of the baby in neonatology (OR 2.88; CI 95% 1.27-6.59), and to maternal psychiatric decompensation during pregnancy (OR 2.60; CI 95% 1.15-6.20), independently from maternal neglectful behaviors. Low family/social support showed a trend towards association with separation (OR 2.17; CI 95% 0.91-5.42). This study shows that separation is mostly linked to mothers' environmental and interactive past and current history, to the child's health, and to maternal mental health decompensation. The identification of these factors is essential to implement antenatal prevention and social programs for these women. Further studies should focus on the long-term development of children of schizophrenic mothers, whether or not they have been placed, in order to help clarifying the impact of the risk factors.

Economic Burden, Mortality, and Institutionalization in Patients Newly Diagnosed with Alzheimer's Disease.

BACKGROUND: Current information is scarce regarding comorbid conditions, treatment, survival, institutionalization, and health care utilization for Alzheimer's disease (AD) patients. OBJECTIVES: Compare all-cause mortality, rate of institutionalization, and economic burden between treated and untreated newly-diagnosed AD patients. METHODS: Patients aged 65-100 years with ≥1 primary or ≥2 secondary AD diagnoses (ICD-9-CM:331.0] with continuous medical and pharmacy benefits for ≥12 months pre-index and ≥6 months post-index date (first AD diagnosis date) were identified from Medicare fee-for-service claims 01JAN2011-30JUN2014. Patients with AD treatment claims or AD/AD-related dementia diagnosis during the pre-index period were excluded. Patients were assigned to treated and untreated cohorts based on AD treatment received post-index date. Total 8,995 newly-diagnosed AD patients were identified; 4,037 (44.8%) were assigned to the treated cohort. Time-to-death and institutionalization were assessed using Cox regression. To compare health care costs and utilizations, 1 : 1 propensity score matching (PSM) was used. RESULTS: Untreated patients were older (83.85 versus 81.44 years; p < 0.0001), with more severe comorbidities (mean Charlson comorbidity index: 3.54 versus 3.22; p < 0.0001). After covariate adjustment, treated patients were less likely to die (hazard ratio[HR] = 0.69; p < 0.0001) and were associated with 20% lower risk of institutionalization (HR = 0.801; p = 0.0003). After PSM, treated AD patients were less likely to have hospice visits (3.25% versus 9.45%; p < 0.0001), and incurred lower annual all-cause costs ($25,828 versus $30,110; p = 0.0162). CONCLUSION: After controlling for comorbidities, treated AD patients have better survival, lower institutionalization, and sometimes fewer resource utilizations, suggesting that treatment and improved care management could be beneficial for newly-diagnosed AD patients from economic and clinical perspectives.

The Effects of Psychosocial Deprivation on Attachment: Lessons from the Bucharest Early Intervention Project.

The absence of typical caregiving, including warm and responsive parenting, has been suggested to significantly affect the young child's ability to form adaptive relationships with adults and peers. The Bucharest Early Intervention Project (BEIP), a randomized controlled trial of foster/family care for young children with a history of institutionalization has provided the context to assess these relationships. Here we review data from the BEIP with specific focus on attachment. The findings clearly show the importance of early family care on the emergence of attachment, on the prevention of psychopathology, and on links between brain and social behavior.

The psychiatric treatment of 'behavioural problems' in adolescence: Between coercion and socialisation.

A 2005 report from the French Institute for Medical Research highlighted factors likely to prompt 'behavioural problems' in children and adolescents, and recommended early identification of at-risk families. A number of mental health professionals rose up against such medicalisation of social issues. This ethnographic study was conducted in this climate, in a psychiatric unit, located in a disadvantaged area in the outskirts of Paris, that specialises in adolescents with such problems. The research emphasised how professionals resist being instrumentalised by juvenile counselling services and the justice system, the observed practices bearing traces of critiques of psychiatric institutions since the 1960s. Psychiatrists thus try to justify and legitimate their interventions, which are co-constructed by relevant counselling and mental health professionals and, as much as possible, adolescents and their parents. Consequently, full understanding of institutionalisation, beyond its aspects of constraint and subjection, also requires consideration of its potential as a step in the socialisation process, especially for adolescents from working class backgrounds bereft of social and cultural capital. Contact with professionals may confer a kind of power, 'the power to speak'. At least, that is what the professionals try to give them using the 'pedagogy of reflexivity'.

Discordance between physician-rated health and an objective health measure among institutionalized older people.

BACKGROUND: Although physician-rated health is emerging as a potentially useful variable in research, with implications in practice, it has not been analyzed. Moreover, one of its most important aspects, namely, concordance with patients' objective health state, has not been investigated. This study sought to measure concordance between physician-rated health and an objective health measure, and assess both measures' validity in predicting death. METHODS: The data for the study were drawn from a 1998-1999 survey and subsequent mortality follow-up of residential and nursing homes in Madrid (Spain). Study subjects were 630 residents aged ≥65 years, and their respective facility physicians. Measures included agreement between physicians' rating of residents' overall health (good, intermediate or poor) and an objective measure of residents' health (good, intermediate or poor), based on functional capacity, cognitive status, and number of chronic conditions. Overrating was defined as any case where health, rated as good by a physician, was objectively rated as poor. RESULTS: Whereas 45% of physicians and 55% of residents rated their health as good, only 4% of such residents had good objective health. Of those who received a physician rating of good/very good health, 39.0% had poor objective health. There was evidence of clear overrating in 18% of the population, and clear to moderate overrating in 73% of the population. In terms of power to predict mortality, the pattern of behavior shown by the objective health measure was good, graded and congruent, and better than that shown by physician-rated health. CONCLUSION: Physician overrating of the overall health of older persons in residential and nursing homes, would appear to be very high. Although some degree of contextualization by physicians in this setting might be considered reasonable, the degree of overrating in our population seems nevertheless excessive.