The clinical case against tube feeding in palliative care of the elderly.

The terminal stages of many neurological illnesses occurring in the elderly produce feeding and swallowing problems. These difficulties lead to ethical, religious, philosophical, and medico-legal conflicts when decisions about starting or stopping tube feedings are considered. We present the case against all forms of tube feeding in a particular subset of elderly palliative patients. These are individuals who are in the end-stage of a progressive neurological disease who are noncommunicative, and spend all or most of their time in a recumbent position. We discuss the physiological phenomena existing in these patients that make the probability of aspiration pneumonia as great or possibly greater than with careful spoon feeding. If tube feeding results in the outcome that it is thought to prevent (ie, aspiration pneumonia) then decisions regarding nutritional support in these patients become clinically clearer.

Abnormal speech articulation, psychomotor retardation, and subcortical dysfunction in major depression.

Psychomotor retardation, characterized by changes in speech, motility and cognition, is common in major depression. It is also a cardinal feature of subcortical disorders such as Parkinson's disease (PD). Based on this observation and other data it has been hypothesized that the retardation of depression is related to mesolimbic-nigrostriatal dysfunction. To further test this hypothesis, speech articulation in major depression was compared to that in PD, where disordered articulation is related to bradykinesia and rigidity caused by striatal dopamine depletion. Thirty subjects with major depression were compared with 30 patients with PD and 31 normal controls on 3 acoustic measures of articulation. Major depression and PD groups had significantly shortened voice onset time and decreased second formant transition compared to controls, and major depression also had increased spirantization. There were no differences between the depression and PD groups on any of the acoustic measures. These findings provide indirect support for the hypothesis that nigrostriatal dysfunction is related to psychomotor slowing in major depression.

The differential diagnosis of Alzheimer's disease: conceptual and methodological issues.

The study of Alzheimer's disease is hampered by insufficient knowledge of its cause. It can best be described as a syndrome whose clinical and pathological features, and their associations over time, need to be more carefully examined. Issues which impede our understanding of this syndrome include the lack of: a singular "gold standard" for its identification; longitudinal studies with appropriate comparison groups and neuropathological follow-up; and standardized multifaceted clinical assessment procedures. Our awareness of the significance of these issues has led us to undertake a large-scale prospective, longitudinal investigation of 399 dementing and normal individuals at Sunnybrook Medical Centre. As a result of problems identified, it is proposed that research efforts across various Canadian centres be coordinated to best utilize available resources and expertise.

Acoustic analysis in the differentiation of Parkinson's disease and major depression.

In its early stages, Parkinson's disease (P.D.) may be difficult to distinguish from major depression (M.D.) leading to inappropriate management. Both illnesses are characterized by psychomotor retardation. The neurovegetative symptoms used to diagnose M.D. are not specific and in P.D. may be due to the physical illness itself. Currently, differentiation of the two disorders relies on subjective clinical observation. Improved diagnostic accuracy based on more objective data is needed. To this end, this study used computerized acoustic analysis to contrast speech patterns in P.D. and M.D. The sample consisted of 30 P.D. patients without depression or dementia, 30 patients with uncomplicated M.D., and 31 normal controls, each 60 years of age or over. Of the acoustic variables studied, M.D. patients had significantly reduced rates of speech compared with P.D. patients. The data suggest that this temporal measure of speech may be useful in the differentiation of P.D. and M.D.