Advance care planning and proxy decision making for patients with advanced Parkinson disease.

OBJECTIVES: To examine advance care planning practices and proxy decision making by family healthcare proxies for patients with advanced Parkinson disease (PD). METHODS: Sixty-four spouses and adult children, self-designated as a/the healthcare proxy for advanced patients with PD, participated in a cross-sectional survey study. RESULTS: Sixty patients with PD (95%) had completed a living will, but only 38% had shared the document with a physician. Among three life-support treatments--cardiopulmonary resuscitation (CPR), ventilator, and feeding tube--47% of patients opted for CPR, 16% for ventilator, and 20% for feeding tube. Forty-two percent of proxies did not know patients' preferences for one or more of the three life-support treatments. Only 28% of proxies reported that patients wanted hospice. Patients who shared advance directives with a physician were significantly less likely to choose CPR and a feeding tube and they were more likely to choose hospice. In a hypothetical end-of-life (EOL) scenario, the majority of proxies chose comfort care as the EOL goal of care (53%) and pain and symptom management only as the course of treatment option (72%); these proxy choices for patients, however, were not associated with patients' preferences for life support. Patients' proxies preferred a form of shared decision making with other family members and physicians. CONCLUSIONS: Advance care planning is effective when patients, families, and healthcare professionals together consider future needs for EOL care decisions. Further efforts are needed by healthcare professionals to provide evidence-based education about care options and facilitate advanced discussion and shared decision making by the patient and families.

Parkinson disease: research update and clinical management.

More than 1 million people in the United States have Parkinson disease (PD), more than are diagnosed as having multiple sclerosis, amyotrophic lateral sclerosis, muscular dystrophy, and myasthenia gravis combined. PD affects approximately 1 in 100 Americans older than 60 years. It burdens patients, their care partners, and the overall healthcare system. This article reviews the epidemiology, clinical features, putative environmental risk and protective factors, neuropathological aspects, heterogeneity, medical management, and recent studies regarding genetics and PD. The article suggests that based on new research, the prevalence of PD varies in different regions of the United States. Some progress has been made in identifying the risk and protective factors of PD, and a newly emphasized area of study in PD is genetics. Patient care recommendations, based on American Academy of Neurology practice guidelines, are outlined to show the state of contemporary medical management of PD and related disorders.

Prevalence and Cognitive Bases of Subjective Memory Complaints in Older Adults: Evidence from a Community Sample.

Objectives. To estimate the prevalence of subjective memory complaints (SMCs) in a sample of community-dwelling, older adults and to examine cognitive bases of these complaints. Participants. 499 community-dwelling adults, 65 and older. Measurements. A telephone survey consisting of cognitive tests and clinical and sociodemographic variables. SMCs were based on subjects' evaluations and subjects' perceptions of others' evaluations. Analysis. Logistic regression was used to model the risk for SMCs as a function of the cognitive, clinical, and sociodemographic variables. We tested for interactions of the cognitive variables with age, education, and gender. Results. 27.1% reported memory complaints. Among the younger age, better objective memory performance predicted lower risk for SMCs, while among the older age, better memory had no effect on risk. Among the better-educated people, better global cognitive functioning predicted lower risk for SMCs, while among the less-educated people, better global cognitive functioning had no effect on SMC risk. When predicting others' perceptions, better objective memory was associated with lower risk for SMCs. Conclusion. Objective memory performance and global cognitive functioning are associated with lower risk for SMCs, but these relationships are the strongest for the younger age and those with more education, respectively. Age and education may affect the ability to accurately appraise cognitive functioning.

Assessing executive function in Parkinson disease: the alternating names test. Part I. Reliability, validity, and normative data.

OBJECTIVES: To evaluate psychometric properties (convergent and divergent validity; alternate forms reliability) and provide normative data for the Alternating Names Test (ANT), a new bedside test of set-switching, a component of executive function (EF). The test was specifically designed for use in persons with Parkinson disease (PD). DESIGN: Cross-sectional study. SETTING: Clinic-based PD Research Registry. PARTICIPANTS: Data were gathered from two samples: 829 patients with idiopathic PD enrolled in our clinic registry and 253 caregivers and family members of patients. MEASUREMENTS: In the ANT, patients are asked to produce the names of children, switching back and forth from boys' to girls' names. Outcome measures include the time to complete ten correct pairs and the number of errors made. RESULTS: Correlations between the ANT and similar constructs were high (mean Spearman rank-order correlation coefficient, rho=.67), indicating good convergent validity. Measures of divergent validity were low (mean Spearman's rho=.31), demonstrating good divergent validity. Alternate forms reliability was high for time (rho=.76), but low for errors (rho=.37). Normative data are presented in a look-up table. CONCLUSION: Our test is a valid and reliable measure of set-switching in PD. Its ease of administration and effectiveness in identifying executive deficits suggests that the test could be useful in clinical practice and warrants further study.

Postoperative cognitive dysfunction in older patients with a history of alcohol abuse.

BACKGROUND: Postoperative cognitive dysfunction (POCD) affects a significant number of patients and may have serious consequences for quality of life. Although POCD is most frequent after cardiac surgery, the prevalence of POCD after noncardiac surgery in older patients is also significant. The risk factors for POCD after noncardiac surgery include advanced age and preexisting cognitive impairment. Self-reported alcohol abuse is a risk factor for postoperative delirium, but its significance for long-term POCD has not been investigated. The goal of this study was to determine whether neurocognitive function is impaired after noncardiac surgery during general anesthesia in older patients with a history of alcohol abuse. METHODS: Subjects aged 55 yr and older with self-reported alcohol abuse (n = 28) and age-, sex-, education-matched nonalcoholic controls (n = 28) were tested using a neurocognitive battery before and 2 weeks after elective surgery (n = 28) or a corresponding time interval without surgery (n = 28). Verbal memory, visuospatial memory, and executive functions were assessed. A neurologic examination was performed to exclude subjects with potential cerebrovascular damage. RESULTS: Significant three-way interactions (analysis of variance) for Visual Immediate Recall, Visual Delayed Recall, Semantic Fluency, Phonemic Fluency, and the Color-Word Stroop Test implied that cognitive performance in the alcoholic group decreased after surgery more than it did in the other three groups. CONCLUSIONS: The results suggest that a history of alcohol abuse in older patients presents a risk for postoperative cognitive impairment in the domains of visuospatial abilities and executive functions that may have important implications for quality of life and health risks.