Guardianship Before and Following Hospitalization.

When ethics committees are consulted about patients who have or need court-appointed guardians, they lack empirical evidence about several common issues, including the relationship between guardianship and prolonged, potentially medically unnecessary hospitalizations for patients. To provide information about this issue, we conducted quantitative and qualitative analyses using a retrospective cohort from Veterans Healthcare Administration. To examine the relationship between guardianship appointment and hospital length of stay, we first compared 116 persons hospitalized prior to guardianship appointment to a comparison group (n = 348) 3:1 matched for age, diagnosis, date of admission, and comorbidity. We then compared 91 persons hospitalized in the year following guardianship appointment to a second matched comparison group (n = 273). Mean length of stay was 30.75 days (SD = 46.70) amongst those admitted prior to guardianship, which was higher than the comparison group (M = 7.74, SD = 9.71, F = 20.75, p < .001). Length of stay was lower following guardianship appointment (11.65, SD = 12.02, t = 15.16, p < .001); while higher than the comparison group (M = 7.60, SD = 8.46), differences were not associated with guardianship status. In a separate analysis involving 35 individuals who were hospitalized both prior to and following guardianship, length of stay was longer in the year prior (M = 23.00, SD = 37.55) versus after guardianship (M = 10.37, SD = 10.89, F = 4.35, p = .045). In qualitative analyses, four themes associated with lengths of stay exceeding 45 days prior to guardianship appointment were: administrative issues, family conflict, neuropsychiatric comorbidity, and medical complications. Our results suggest that persons who are admitted to hospitals, and subsequently require a guardian, experience extended lengths of stay for multiple complex reasons. Once a guardian has been appointed, however, differences in hospital lengths of stay between patients with and without guardians are reduced.

Episodic Memory and Executive Function Are Differentially Affected by Retests but Similarly Affected by Age in a Longitudinal Study of Normally-Aging Older Adults.

Episodic memory and executive function are two cognitive domains that have been studied extensively in older adults and have been shown to decline in normally-aging older individuals. However, one of the problems with characterizing cognitive changes in longitudinal studies has been separating effects attributable to normal aging from effects created by repeated testing or practice. In the present study, 166 people aged 65 and older were enrolled over several years and tested at least 3 times at variable intervals (M = 3.2 yrs). The cognitive measures were composite scores. Each composite was made up of five neuropsychological tests, previously identified through factor analysis. For one pair of composite scores, variance attributable to age was removed from each subtest through regression analyses before z-scores were computed, creating two age-corrected composites. A second pair of composites were not age-corrected. Using linear mixed-effects models, we first explored retest effects for each cognitive domain, independent of age, using the age-corrected composites. We then modeled aging effects using the age-uncorrected composites after subtracting out retest effects. Results indicated significant retest effects for memory but not for executive function, such that memory performance improved across the three testing sessions. When these practice effects were removed from the age-uncorrected data, effects of aging were evident for both executive and memory function with significant declines over time. We also explored several individual difference variables including sex, IQ, and age at the initial testing session and across time. Although sex and IQ affected performance on both cognitive factors at the initial test, neither was related to practice effects, although young-older adults tended to benefit from practice to a greater extent than old-older adults. In addition, people with higher IQs showed slower age-related declines in memory, but no advantages in executive function. These findings suggest that (a) aging affects both memory and executive function similarly, (b) higher IQ, possibly reflecting cognitive reserve, may slow age-related declines in memory, and (c) practice through repeated testing enhances performance in memory particularly in younger-older adults, and may therefore mask aging effects if not taken into account.

Help Me Understand: Providing Palliative Care to Individuals With Serious Mental Illness.

Individuals with serious mental illness (SMI) have shortened life expectancy with increased risk of developing comorbid medical illnesses. They might have difficulty accessing care and can be lost to follow-up due to complex socioeconomic factors, placing them at greater risk of dying from chronic or undiagnosed conditions. This, in combination with stigma associated with SMI, can result in lower quality end-of-life care. Interdisciplinary palliative care teams are in a unique position to lend assistance to those with SMI given their expertise in serious illness communication, values-based care, and psychosocial support. However, palliative care teams might be unfamiliar with the hallmark features of the various SMI diagnoses. Consequently, recognizing and managing exacerbations of SMI while delivering concurrent palliative or end-of-life care can feel challenging. The goal of this narrative review is to describe the benefits of providing palliative care to individuals with SMI with concrete suggestions for communication and use of recovery-oriented language in the treatment of individuals with SMI. The salient features of 3 SMI diagnoses-Bipolar Disorders, Major Depressive Disorder, and Schizophrenia-are outlined through case examples. Recommendations for working with individuals who have SMI and other life-limiting illness are provided, including strategies to effectively manage SMI exacerbations.

End-of-Life Care for Persons Under Guardianship.

CONTEXT: Guardians are surrogate decision makers appointed by a court when other health care decision-makers are unable, unwilling, or unavailable to make decisions. Prior studies suggest that persons under guardianship may experience delays in transitions of care. OBJECTIVES: To compare quality of end-of-life care for persons under guardianship to a matched group on objective indicators and to identify narrative themes characterizing potential obstacles to quality end-of-life care. METHODS: One hundred sixty-seven persons under guardianship who died between 2003 and 2019 within the Veterans Healthcare Administration in Massachusetts and Connecticut matched on a 1:1 basis to persons without guardians. The groups were compared on treatment specialty at death, days of hospice and intensive care unit care, and receipt of palliative care consultation. Additionally, patient narratives for those under guardianship with extended lengths in intensive care unit were subjected to qualitative analysis. RESULTS: Overall, <1% were under guardianship. Within this sample of persons who died within the Veterans Health Administration, persons under guardianship were as likely as patients in the comparison group to receive palliative care consultation (odds ratio [CI] = 0.93 [.590-1.46], P = .359), but were more likely to have ethics consultation (odds ratio [CI] = 0.25 [0.66-0.92], P = .036) and have longer lengths of ICU admission (ß = -.34, t = -2.70, P = .009). Qualitative findings suggest that issues related to family conflict, fluctuating medical course, and limitations in guardian authority may underlie extended lengths of stay. CONCLUSION: Guardianship appears to be rare, and as a rule, those under guardianship have equal access to hospice and palliative care within Veterans Health Administration. Guardianship may be associated with health-care challenges in a small number of cases, and this may drive perceptions of adverse outcomes.

Differences between young and older adults in unity and diversity of executive functions.

Miyake and colleagues (2000) identified three independent but correlated components of executive function in young adults - set shifting, inhibition, and updating. The present study compared the factor structure in young adults to two groups of older adults (ages 60-73 and 74-98). A three-factor model of shifting, inhibition and updating was confirmed in young adults, but the factors were weakly or uncorrelated. In both older groups, a two-factor solution was indicated, updating/inhibition and shifting, which were moderately correlated in young-older adults, and strongly correlated in the old-older group. A nested factors model in the oldest group revealed a common factor, which loaded on all but one of the tests, and a shifting-specific factor. We concluded that in young adulthood, shifting, updating and inhibition may operate relatively independently. As people age and processing becomes less efficient, they may rely increasingly on general executive control processes, reallocating their limited resources to optimize performance.

Working memory predicts subsequent episodic memory decline during healthy cognitive aging: evidence from a cross-lagged panel design.

Aging adults experience declines in working memory and episodic memory, however, it is unclear how these declines operate over time. Decreased working memory may be associated with early changes in episodic memory, by reducing older adults' ability to meaningfully integrate new information into pre-existing schemas and recall information without the assistance of cues. Given the increased prevalence of Alzheimer's disease, and concerns based on subjective memory changes, it is important to understand how these processes interact over time. To assess the relationship between working memory and episodic memory during healthy cognitive aging, we performed neuropsychological assessments at multiple time points in a sample of 310 community-dwelling older adults. Using a cross-lagged panel design, we demonstrated that the lagged associations between working memory and later episodic free recall were 50% larger than the lagged associations between episodic recall and later working memory, suggesting working memory may be a useful metric of future episodic memory decline.

Self-reference and emotional memory effects in older adults at increased genetic risk of Alzheimer's disease.

The present study investigated whether cognitively healthy older adults who are carriers of the ε4 allele of apolipoprotein E, the most prevalent genetic risk factor for late-onset Alzheimer's disease, benefit from self-referential processing and emotional processing to the same degree as noncarriers of this gene. Participants encoded emotional and nonemotional narratives using a baseline-orienting task, semantic elaboration, or imagination-based self-referential processing and then completed a recognition memory test. Both groups of older adults showed enhanced recognition memory for narrative information following self-referential processing relative to semantic elaboration, and the magnitude of this memory effect was not affected by ε4 status. However, older adult ε4 carriers did not show an emotional enhancement effect, whereas older adult ε4 noncarriers did. These results indicate that whereas the self-reference effect is not attenuated in cognitively healthy older adults ε4 carriers, deficits in emotional memory may be an early cognitive marker of abnormal decline.

Social cognition and the course of social functioning in first-episode psychosis.

BACKGROUND: Social functioning deficits greatly affect individuals with psychotic disorders resulting in decreased ability to maintain relationships, jobs and pursuit of educational goals. Deficits in social cognition have been hypothesized to be an important contributor to these deficits in social functioning. In particular, 5 domains of social cognition have been suggested to be relevant in the study of psychotic disorders: (1) attributional style, (2) emotion recognition, (3) social knowledge, (4) social perception and (5) theory of mind. Yet, to date, no study has simultaneously investigated the association between these 5 domains of social cognition and social functioning. METHODS: We investigated the cross-section and longitudinal association between social cognition and social functioning among 71 individuals with first-episode psychosis. RESULTS: We found modest cross-sectional associations between social cognition and social functioning that were often in the unexpected direction (ie, greater social cognition associated with worse social functioning). Social cognition at baseline was not associated with the longitudinal course of social functioning. CONCLUSIONS: These unexpected findings fail to align with previous research that has documented a more robust relationship between these 2 constructs, and raise critical questions with regard to the nature of the association between social cognition and social functioning among individuals with first-episode psychosis.