Survival of hospitalized elderly patients with delirium: a prospective study.

The authors tested the relationship between clinically diagnosed delirium during hospitalization and increased mortality after accounting for pre-hospital measures of global cognition, physical functioning, and medical comorbidity. Patients (N=102), 53 of which were hospitalized during the course of a year, received the Mini-Mental State Exam, Physical Self-Maintenance Scale, Cumulative Illness Rating Scale, and 15-item Geriatric Depression Scale. Mortality rates were determined at discharge and after 3 years. Patients who developed delirium did not differ on pre-hospitalization levels of depression, global cognitive performance, physical functioning, or medical comorbidity. Three-year mortality in the hospitalized subjects was 75% for delirium patients vs. 51% for control patients (risk ratio=2.24). Delirium occurring during hospitalization places elderly subjects at long-term risk of mortality. This effect is not accounted for by earlier measures of cognitive, functional, or health status.

Validating the diagnosis of delirium and evaluating its association with deterioration over a one-year period.

The authors probed the associations between clinical diagnoses and independent research measures of cognitive, behavioral, and electroencephalographic (EEG) changes in hospitalized older patients and investigated the contribution of medical illness to deterioration. Patients (N=96; 47 of whom were hospitalized during the course of 1 year; 12 diagnosed with delirium) received tests of cognitive and physical functioning and the Cumulative Illness Rating Scale, specific neuropsychological tests, and a two-channel EEG. Delirium was associated with independent measures of cognitive decline and EEG slowing. Hospitalization was associated with deterioration in functional status during the year, whether or not patients showed delirium. Results suggest that medical illness leading to hospitalization can contribute significantly to deterioration in self-care, and, when it is associated with delirium, to deterioration in cognitive performance and cerebral activity over a period of 1 year.

Chronic pain. Sources of late-life pain and risk factors for disability.

The prevalence of pain peaks in middle age and decreases thereafter, according to most epidemiologic studies of complaints of pain. However, this apparent decrease in pain in older adults may be a statistical artifact. Eighty to 85% of persons experience a significant health problem that predisposes them to pain at some time after age 65. With aging, patients experience less frequent head, abdominal, and chest pain and more frequent joint pain. Women are more likely to report musculoskeletal pain and multiple pain sites than men, but there are no gender differences for reports of chest and abdominal pain. Many patients with chronic pain have clinically significant depressive symptoms and low self-reported quality-of-life scores.

The effects of pain and depression on physical functioning in elderly residents of a continuing care retirement community.

UNLABELLED: OBJECTIVE. Explore the relationships between pain, depression, and functional disability in elderly persons. DESIGN: A cross-sectional, observational study of 228 independently living retirement community residents. METHODS: Self-report measures of pain (adaptation of McGill Pain Questionnaire), depression (Geriatric Depression Scale [GDS]) and physical functioning (Physical performance difficulties, activities of daily living [ADL], independent activities of daily living [IADL], and 3-meter walking speed) were employed. OUTCOME MEASURES: Physical functioning variables were dichotomized. Individuals in the lowest quartiles of functional performance and of walking speed were contrasted to all others; for ADL and IADL, those needing some help were compared with those independent in activities. RESULTS: Pain and depression levels were strongly related to physical performance; depression levels were related to ADL and walking speed. In multivariate analyses, an interaction effect was observed where the effects of pain were a function of level of depression. Individuals reporting activity-limiting pain and slightly elevated depressive symptom levels, sub-threshold depression, or major depression were significantly more likely (AOR 7.8; 95% CI, 3.07-20.03) than non-depressed persons to be in the lowest quartile of self-reported physical performance. CONCLUSIONS: While both pain and depression level affect physical performance, depressive symptoms rather than pain appear the more influential factor. When seeing elderly patients, identifying, evaluating, and treating both pain complaints and depressive symptoms and disorders may reduce functional impairment.

Diagnosis and treatment of depression in late life. Consensus statement update.

OBJECTIVE: To reexamine the conclusions of the 1991 National Institutes of Health Consensus Panel on Diagnosis and Treatment of Depression in Late Life in light of current scientific evidence. PARTICIPANTS: Participants included National Institutes of Health staff and experts drawn from the Planning Committee and presenters of the 1991 Consensus Development Conference. EVIDENCE: Participants summarized relevant data from the world scientific literature on the original questions posed for the conference. PROCESS: Participants reviewed the original consensus statement and identified areas for update. The list of issues was circulated to all participants and amended to reflect group agreement. Selected participants prepared first drafts of the consensus update for each issue. All drafts were read by all participants and were amended and edited to reflect group consensus. CONCLUSIONS: The review concluded that, although the initial consensus statement still holds, there is important new information in a number of areas. These areas include the onset and course of late-life depression; comorbidity and disability; sex and hormonal issues; newer medications, psychotherapies, and approaches to long-term treatment; impact of depression on health services and health care resource use; late-life depression as a risk factor for suicide; and the importance of the heterogeneous forms of depression. Depression in older people remains a significant public health problem. The burden of unrecognized or inadequately treated depression is substantial. Efficacious treatments are available. Aggressive approaches to recognition, diagnosis, and treatment are warranted to minimize suffering, improve overall functioning and quality of life, and limit inappropriate use of health care resources.

Occult liver abscess following clinically unsuspected ingestion of foreign bodies.

Two uncommon cases of foreign body (a wooden clothespin and a toothpick) perforation of the gur with associated pyogenic liver abscesses are presented. These cases illustrate the difficulties of preoperative diagnosis. The lack of history of ingestion of foreign bodies, variable clinical presentation of the conditions and radiolucent natures of the foreign bodies all play a role in impeding the diagnosis preoperatively. This report emphasizes the role of ultrasound and computed tomographic scan in evaluating similar cases. Any patient with known risk factors for ingestion of foreign body should arouse suspicion and be investigated further.

Effectiveness of a psychosocial intervention, interpersonal counseling, for subdysthymic depression in medically ill elderly.

BACKGROUND: Subdysthymic depression occurs in 20-50% of hospitalized elderly and is associated with physical and social disability, delayed recovery, and excess health service use. Despite this, little is known regarding the nature of such depressive symptomatology, or its responsivity to treatment. To address this, a randomized clinical trial assessing the feasibility and efficacy of Interpersonal Counseling (IPC), a short-term psychotherapy, was conducted. METHODS: Patients 60+ with a Geriatric Depression Scale (GDS) score > 10 not meeting DSM-III-R criteria for major depression or dysthymia were recruited from the acute hospital. Thirty-five individuals were randomized to IPC and 41 to usual care (UC). IPC was delivered following hospital discharge by psychiatric clinical nurse specialists. Interviews were conducted at recruitment and 3, 6, and 12 months later. Primary outcomes were GDS scores, health ratings, and measures of physical and social functioning. RESULTS: At 3 months, IPC group members showed greater improvement than UC members on all outcome variables; between-group differences did not reach statistical significance. At 6 months, a statistically significant difference in the rate of improvement in GDS, indicated by scores of 10 or less, was observed for IPC compared to UC members (60.6% vs 35.1%). Multivariate analyses confirmed a positive treatment effect on depressive symptoms. Similar multivariate analyses showed a statistically significant positive treatment effect on self-rated health but not on physical or social functioning. CONCLUSIONS: IPC appears feasible, acceptable, and effective in short-term depressive symptom reduction and in improvement in self-rated health. Implementation of IPC interventions for subdysthymic hospitalized elderly is recommended.

Does treatment of asymptomatic bacteriuria in older ambulatory women reduce subsequent symptoms of urinary tract infection?

OBJECTIVE: To determine whether treatment of symptomatic bacteriuria in older ambulatory women affects the subsequent development of symptoms of urinary tract infection. DESIGN: A controlled clinical trial. PARTICIPANTS: Older women not having urinary catheters. MEASUREMENTS: Urine cultures every 6 months (the same organism at 10(5) colony-forming units or more per mL on two midstream urine specimens defined asymptomatic bacteriuria) and questionnaire surveys for the new development of symptoms of urinary tract infection (dysuria, frequency, urgency, low back pain with fever) 1, 3, and 6 months after the initial survey. RESULTS: Of the 23 initially culture-positive participants receiving antibiotic treatment for symptomatic bacteriuria, nine were culture positive at 6 months, which contrasts with 18 of 27 who received no treatment or placebo, P = .05. However, symptoms of urinary tract infection were more common in the antibiotic-treated group. CONCLUSION: Antibiotic therapy effectively reduced the subsequent occurrence of positive urine cultures, but symptoms were not reduced. Based on this study of morbidity, previous studies failing to show any relation to mortality, and the cost and complications of antibiotic therapy in the older population, treatment of asymptomatic bacteriuria in older women is contraindicated.

Social support, depression, and recovery of walking ability following hip fracture surgery.

The importance of social support and depression to recovery from illness is examined with reference to hip fracture. Subjects were community-dwelling, ambulatory White females 59 years of age and over who were recovering from hip fracture surgery. The respondents were interviewed at baseline and clinically interviewed 2 and 6 months postsurgery. Inadequacy of social support and depression resulted in less improvement in walking ability at 2 months. By 6 months, the flow of casual influence was in the reverse direction, with low improvement in walking ability leading to increased level of depression. Social support's influence mediated the impact of health and background factors, but this was primarily at 2 months. If social support is to influence recovery, it must be present early in the recovery process. Social support's long-term consequences are indirectly operating through recovery measures taken shortly after the illness event.

Esophagotomy for incarcerated esophageal foreign bodies.

Less than 1% of esophageal foreign bodies are irretrievable by endoscopic techniques. Incarcerated esophageal foreign bodies require esophagotomy for removal. A retrospective study was conducted to determine the incidence, predisposing factors, and optimal treatment of incarcerated esophageal foreign bodies. Four of 815 patients (0.5%) with esophageal foreign bodies required esophagotomy for foreign body removal. Two predisposing factors for incarceration were identified, and these factors were related to patient age. Two infants had neglected esophageal foreign bodies that partially migrated through the esophageal wall. In two adults, foreign body size and sharpness were responsible for incarceration. One cervical and three thoracic esophagotomies were done. One thoracic esophagotomy suture line dehiscence occurred. Occult foreign body pressure necrosis may be a factor in esophagotomy suture line leakage. Care is required in esophagotomy closure. Principles established for repair of esophageal perforations are also applicable to esophagotomy closure.

Does asymptomatic bacteriuria predict mortality and does antimicrobial treatment reduce mortality in elderly ambulatory women?

OBJECTIVE: To determine whether asymptomatic bacteriuria in elderly ambulatory women is a marker of increased mortality and, if so, whether it is because of an association with other determinants of mortality or because asymptomatic bacteriuria is itself an independent cause, the removal of which might improve longevity. DESIGN: A cohort study and a controlled clinical trial of the effect of antimicrobial treatment. SETTING: A geriatric center and 21 continuing care retirement communities. PARTICIPANTS: Women without urinary tract catheters. MEASUREMENTS: Urine cultures every 6 months (the same organism at 10(5) colony-forming units or more per mL on two midstream urine specimens defined asymptomatic bacteriuria), comorbidity, and mortality. RESULTS: In the observational study, infected residents (n = 318) were older, and sicker, and had higher mortality (18.7 per 100,000 resident-days) than uninfected residents (n = 1173; 10.1 per 100,000 resident-days). However, in a multivariate Cox analysis, infection was not related to mortality (relative risk, 1.1; P > 0.2), whereas age at entry and self-rated health (score 1 [excellent] to 4 [bad or poor]) were strong predictors. In the clinical trial, mortality in 166 treated residents (13.8 per 100,000 resident-days) was comparable to that of 192 untreated residents (15.1 per 100,000 resident-days); the relative rate was 0.92 (95% CI, 0.57 to 1.47). The cure rates among treated and untreated residents were 82.9% and 15.6%, respectively. CONCLUSION: Urinary tract infection was not an independent risk factor for mortality, and its treatment did not lower the mortality rate. Screening and treatment of asymptomatic bacteriuria in ambulatory elderly women to decrease mortality do not appear warranted.

Epidemiology of asymptomatic bacteriuria in elderly women.

We studied asymptomatic bacteriuria in elderly ambulatory women residents without indwelling catheters in self-contained apartment houses at the Philadelphia Geriatric Center (PGC), in the nursing home at PGC, and in several life-care communities (LCC). Subjects were studied every 6 months from January 1983 through January 1989, and since enrollment was continuous some participated in more surveys than others. PGC residents were middle class and lived either in a self care apartment house (CL) or nursing home (NH); LCC residents were middle or upper class. Antimicrobial therapy for asymptomatic bacteriuria was not given by the study team. The ages of the 865 women studied averaged 80.3, 82.8, and 83.3 years in LCC, CL, and NH, respectively. On each survey about 11% at LCC, 18% at CL, and 25% at NH sites had positive cultures. Turnover was high. The conversion rate from a negative to a positive culture was 5% at LCC, 11% at CL, and 8% at NH. The reversion rate from a positive to a negative culture was 33% at LCC, 34% at CL and 31% at NH (P greater than 0.05). Persistent infection with the same organism was uncommon. Infection risk was associated with residence, which was partially explained by a factor evaluating mobility, but was unrelated to age or scores evaluating activities of daily living or mental status. Besides mobility, other more complex factors play a role in the acquisition of infection.

Implications of a mental health intervention for elderly mentally ill residents of residential care facilities.

Unresolved issues of responsibility between mental health and aging systems low priority within the mental health system for serving older RCF residents, and little expectation for the facility to be a treatment environment, all contribute to gaps in service delivery to mentally ill boarding home residents. This article reports the results of a two-year mental health intervention in RCFs. Findings show little intervention impact, but revealed that residents treated were generally socially marginal with weak ego skills, rather than significantly mentally ill. A more intensive program that restructures the facility's milieu to offer planned normal life demands and that models structured programs like milieu treatment, in situ treatment for the younger mentally ill, and programs for developmentally disabled persons is suggested.

Bedside clinical and electrophysiological assessment: assessment of change in vulnerable patients.

Current approaches to the diagnosis of delirium are based upon the recognition of symptoms that emerge in the pathological state. As an alternative, we propose an approach to case identification for research purposes based on the recognition of significant changes in the cognitive or cerebral state of the individual patient. Categorical change can be defined using prediction intervals calculated from repeated measures on a population of medically stable subjects. Data from subjects enrolled in a prospective study of delirium in a long-term care population were utilized to calculate prediction intervals for the Mini-Mental Status Examination and for measures of the electroencephalographic background frequency as obtained with a two-channel microprocessor-based EEG device. Preliminary findings support the validity of this quantitative approach for defining changes in brain state. Future research should evaluate both cognitive and electrophysiological techniques for monitoring vulnerable patients.

The effects of persistent depressive symptoms on hip fracture recovery.

One hundred ninety-six older. White females were followed for 12 months after hip fracture. We examined the effects of persistently elevated depressive symptoms, measured by the Center for Epidemiological Studies Depression (CES-D) scale during a postsurgery interview and 2, 6, and 12 months later, on ambulation, overall physical function, and return to prefracture physical function 12 months after fracture. Age, prefracture physical function, and cognitive status were predictors of recovery. Controlling for these factors, persons consistently reporting few depressive symptoms were three times more likely than those with persistently elevated CES-D scores to achieve independence in walking, nine times more likely to return to prefracture levels in at least five of seven physical function measures, and nine times more likely to be in the highest quartile of overall physical function. These findings emphasize the importance of persistently elevated depressive symptoms for recovery. Routine screening, evaluation, and treatment of depression or depressed mood may be beneficial to the recovering hip fracture patient.

Utilization of a two-channel, microprocessor-based EEG device for monitoring cognitively vulnerable patients.

Several experiments were conducted to validate the use of a two-channel microprocessor-based electroencephalographic (EEG) device for detecting changes in EEG background rhythm in the clinic or at the bedside. The reliability of background measures in healthy individuals was evaluated by obtaining EEG data on 20 control subjects on two occasions separated by at least 1 day. The sensitivity to an experimental toxic encephalopathy was evaluated using measures of EEG and the Buschke Memory Selective Reminding Test after the administration of scopolamine hydrobromide, 0.86 mg subcutaneously, to three healthy volunteers. Postdrug measures of the EEG showed significant group differences from controls at 1 and 2 hours for relative alpha and relative theta power. The drug-induced change for each individual exceeded the predicted range calculated from data on control subjects. These findings suggest the feasibility and the potential utility of this method. This approach was extended to the elderly with measures on 102 subjects (average age, 85 years) living in an institutional setting. EEG measures in the population were of acceptable reliability and were significantly correlated with Mini-Mental State Examination (MMSE) scores (r = -.375 for theta and .357 for beta). Preliminary findings suggest that this method may detect metabolic encephalopathies in the elderly. The study demonstrates the potential value of this approach and suggests the need for further research.

Determinants of recovery 12 months after hip fracture: the importance of psychosocial factors.

The independent contributions to recovery from hip fracture of psychosocial factors including depression, personality, social connectedness, and self-rated health were studied in 219 women age 59 and older (mean age 78.5) who were community dwelling prior to fracture. Initial assessments were conducted shortly after surgery and follow up assessments 2, 6, and 12 months later. By 12 months, 15 patients had died and 15 had entered a nursing home. Substantial declines in physical functioning though not psychosocial status were observed. Only 21 per cent (compared to 81 per cent prefracture) reported walking independently; fewer than 30 per cent had regained reported prefracture levels of physical function. The proportion with elevated depression scores at 12 months was 20 per cent, down from 51 per cent following surgery; 64 per cent rated their health excellent or good at 12 months, up from 43 per cent after surgery. Poor cognitive status and post-surgical self-rated health were predictive of mortality. Among survivors, age, prefracture physical functioning, and cognitive status were associated with recovery in physical function but not psychosocial status. High post-surgery depression scores, but not the other psychosocial factors, were associated with poorer recovery in both functional and psychosocial status. These findings demonstrate the importance of depressive symptoms as one determinant of recovery from hip fracture and support the need to attend to the affective status of hip fracture patients following surgery.

Using administrative data to predict important health outcomes. Entry to hospital, nursing home, and death.

This paper assesses our ability to use administrative data for developing indicators of health status. Traditionally, measures of health status have been derived from interviews. Here indicators from administrative data and from interviews are compared, i.e., their ability to predict important health outcomes for a large representative sample of elderly residents of Manitoba, Canada. Indicators of health status derived from an administrative data system and from health interviews are shown to provide roughly similar predictions of nursing-home entry. Administrative data provide significantly better predictions of death and future hospital entry than do variables from interview data.

Using insurance claims to measure health status: the Illness Scale.

Health insurance systems are generating large numbers of claims filed by physicians and hospitals for reimbursement and accounting purposes. This paper describes and evaluates a measure of health status derived from physician and hospital claims filed for a sample of older Canadians during 1970-1977. Information on the number, type, and seriousness of reported diagnoses and the number and duration of hospitalizations and surgeries during each year were combined to generate annual Illness Scales ranging from 0 to 24. Alpha coefficients, measures of internal consistency, were between 0.82 and 0.84. Consistent with high validity, Illness Scale scores increased with age, were significantly associated with other health measures, and were strongly predictive of death and hospitalization in the following year. The ability to develop valid and reliable health status measures from insurance claims substantially expands the potential use of these data for research and evaluation.

A randomized trial of special packaging of antihypertensive medications.

This article reports a randomized controlled trial designed to test the effects of special packaging of antihypertensive medication on compliance and blood pressure control. One hundred eighty subjects who had exhibited elevated blood pressure greater than 90 mmHg in the two years prior to the study were recruited from patients receiving care at a community hospital-based family medicine practice. After completing preenrollment interviews and blood pressure measurements, subjects were randomly assigned to receive their antihypertensive medications either in the usual vials or in special unit dose-reminder packaging. Follow-up interviews, pill counts, and blood pressure measurements were performed at three-month intervals. There were no statistically significant differences between the control and experimental groups with regard to age, sex, race, employment, education, marital status, insurance coverage, or blood pressure regimens. Prior to the intervention, the experimental group had slightly lower diastolic blood pressure and reported better compliance than the control group. Analyses performed on 165 subjects completing the first follow-up visit revealed no significant improvements in blood pressure control or compliance for patients receiving special medication packaging. While some patients found it easy to remember to take pills packaged using this format, they also found the packages somewhat more difficult and inconvenient to use. In contrast to previously reported work, this study did not demonstrate any significant improvement in compliance with special packaging of antihypertensive medications.