Psychometric differentiation of dementia. Replication and extension of the findings of Storandt and coworkers.

In a previous investigation by Storandt and coworkers, a brief battery of four neuropsychological tests was found to accurately distinguish a sample of patients with senile dementia of the Alzheimer type (SDAT) from normal elderly persons. The present study examined the value of these tests in the distinction between SDAT and dementias of other etiologies. Our results replicated those of Storandt and coworkers in that these tests did distinguish normal persons from patients with both SDAT and other dementias. These tests, however, did not accurately differentiate among the dementias. These results indicate that assessment batteries utilizing additional procedures to supplement cognitive testing are indicated to more accurately discriminate among the dementias.

The NINCDS-ADRDA Work Group criteria for the clinical diagnosis of probable Alzheimer's disease: a clinicopathologic study of 57 cases.

Neuropathologic confirmation is required to validate the NINCDS-ADRDA Work Group criteria for the clinical diagnosis of Alzheimer's disease (AD). Neuropathologic inclusion and exclusion criteria for AD, however, are not uniform. The purpose of this investigation was to examine the confirmation rate for the Work Group criteria against differing neuropathologic criteria for AD. The sample consisted of 57 cases, 22 of which had received a clinical diagnosis of AD. Nine neuropathologic criteria for AD were applied in a blind fashion to each of the 57 cases. Our results indicated that, depending on the neuropathologic criteria applied, the clinicopathologic agreement ranged from 64% to 86%. These findings demonstrate the need for universally accepted neuropathologic and clinical criteria for AD.

On the clinical value of the London Psychogeriatric Rating Scale.

The London Psychogeriatric Rating Scale (LPRS) was administered to 76 probable Alzheimer's patients, 59 patients with dementia unrelated to Alzheimer's, 102 neurologically normal subjects, and 27 patients with symptoms of both Alzheimer's and dementia of other etiologies. By examining the relationships among the four subscales of the LPRS and conducting factor analyses, it was demonstrated that the four subscales were not measuring different phenomena. The internal consistency of the full 36-item scale was high (Cronbach's Alpha = 0.96) indicating the total LPRS score provided a reliable global index of behavioral function. The total LPRS scores correlated with the independently administered Goldfarb Mental Status Examination scores (r = -0.79). The LPRS differentiated between the normals and the combined demented groups and between inpatients and outpatients. The LPRS continues to have clinical value for functional assessments in a non-intrusive manner. The LPRS may be particularly useful in situations where direct assessment of mental status is not practical.

Do geriatric programs decrease long-term use of acute care beds?

OBJECTIVE: To determine whether the introduction of coordinated geriatric and discharge planning services at teaching and community hospitals in Toronto has changed the number of beds occupied by patients awaiting transfer to long-term care institutions. DESIGN: Retrospective review of social work records for the period 1985-1992. SETTING: Two tertiary and four primary acute care hospitals in Metropolitan Toronto. PARTICIPANTS: Hospitals were matched for location, acuity, and teaching affiliation. MAIN OUTCOME MEASURES: The numbers of beds occupied by patients awaiting transfer to nursing homes or chronic care hospitals were noted. RESULTS: In those teaching and community hospitals that had introduced coordinated geriatric and discharge planning services, there was a reduction in the percentage of beds occupied by patients awaiting long-term care placement (average-51%), whereas in hospitals without geriatric services, the percentage of beds occupied by patients awaiting long-term care placement increased (average + 25%) (P = .05 by Fisher's exact method, 95% confidence limit odds ratio 0, .9999). CONCLUSION: The introduction of coordinated geriatric and discharge planning services was associated with a decrease in the percentage of beds occupied by patients awaiting long-term care in both teaching and community hospitals.

Methyl-CCNU and methotrexate therapy in patients with advanced colorectal cancer after failure of 5-fluorouracil chemotherapy.

Thirty-six patients with advanced colorectal cancer whose disease progressed during treatment with 5-fluorouracil (5-FU) chemotherapy were treated with methyl-CCNU and methotrexate. Five patients (14%) achieved a partial response (PR), three (8%) showed disease regression less than that required for a PR, and three (8%) showed evidence of stable disease. Twenty-five patients (69%) progressed on treatment. Tumor regression was seen only in patients with good performance status (ECOG 0.1). The median survival time of patients achieving a PR was 31 weeks. Those patients with stable disease or disease regression less than a PR had median survival times of 49 and 32 weeks, respectively. The comparable figure for those patients with disease progression was 17 weeks. Myelosuppression, principally in the form of leukopenia and thrombocytopenia, was common. Nausea and vomiting were universal with methyl-CCNU, and mucositis and diarrhea occurred commonly due to methotrexate. These results demonstrate the limited activity of chemotherapy in refractory colorectal cancer. They also reaffirm that poor pretreatment performance status should exclude patients from futile attempts at palliative therapy or phase II clinical trials, as these patients derive little or no benefit from them.

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.

The place of cooperation in the examination of neuropsychological impairment.

We examined the relationship between ratings of patient cooperation and neuropsychological test performance in a sample (N = 333) of dementing patients and normal controls. We also examined the stability of the relationship in a subset of this same sample (N = 299) who were retested a year later. All the correlation coefficients in both years were significant, with a median Pearson of.64 in year one and.725 in year two. The test-retest reliability for ratings of cooperativeness over the one-year time period (rated by different examiners) was also significant,r =.64 (p <.0001). This analysis indicates that cooperation plays a significant role in neuropsychological test performance and that ratings of cooperativeness are relatively stable over periods of up to a year in length.

The first international conference on the Palliative Care of the Elderly: an overview.

The effort to examine and improve palliative care for the elderly is actively joined. In Europe, Scandinavia, and North America, at least, issues are slowly being examined in clinical research. The response to the conference was enthusiastic, and new information emerged, for example: British Columbia's "Levels of Intervention" guidelines, Dr Doyle's description of new developments in Geriatric and Palliative Care training and service in the United Kingdom, Dr Triau et al's (Psychogeriatric Nursing Home, Leuven, Belgium) normalization model of care for dementia, and Dr Rory Fisher's argument that instead of using negative DNR orders in palliative care we should instead take a positive approach of specifying what palliative care can provide. Palliative care is not "no treatment;" increasingly we are able to be concrete and specific in our ability to prescribe a range of measures to ensure that our dying elderly die in comfort and without medical, legal, or social intrusion.

Urodynamic characterization of incontinence in the elderly by bladder volume.

Incontinence in the elderly patient usually is of the urgency pattern owing to inappropriate detrusor contraction often termed detrusor instability. We herein describe a bladder volume-based method of urodynamic assessment that may help to characterize subsets of incontinent patients with detrusor instability. The conventional parameters of flow, pressure and electromyography are more difficult to measure and may be less appropriate for selection of therapy.

Oxybutynin chloride for geriatric urinary dysfunction: a double-blind placebo-controlled study.

Twenty-four incontinent elderly institutionalized subjects with detrusor instability participated in a double-blind placebo-controlled trial of oxybutynin chloride. Patients were randomly assigned to oral oxybutynin 5 mg or placebo twice daily. Administration continued for 8 days; a 6-day washout period was followed by the alternative treatment. Incontinence was recorded using a bedside electronic monitor. Four subjects withdrew because of side-effects before completing the trial. There were no clinically significant differences between the oxybutynin and placebo treatments. Both groups experienced side-effects, of which dry mouth was the commonest. Thus, oxybutynin does not appear to be more effective than placebo for the treatment of incontinence in the presence of detrusor instability in elderly institutionalized people.

WAIS-R test-retest reliability in a normal elderly sample.

We examined the 1-year test-retest reliability of WAIS-R Verbal, Performance, and Full-Scale IQs in a sample of 101 older normal individuals (mean age = 67.1). The respective Pearson rs were .86, .85, and .90. The median retest reliability coefficient for the WAIS-R subtests was .71. The test-retest reliability for the Verbal-Performance Discrepancy was .69. These data indicate that IQ scores are reliable in older normal individuals for this retest interval, but less confidence can be placed in the reliability of subtest scores and the Verbal-Performance Discrepancy.