Copy task performance and urinary incontinence in Alzheimer's disease.

The relationship between behavioral symptoms and cognitive impairment in Alzheimer's Disease (AD) is only poorly understood. The aim of the present study was to examine cognitive correlates of urinary incontinence in AD. Although incontinence is generally accepted as an accompaniment of AD, it was our clinical impression that it correlated poorly with global measures of cognitive impairment. A retrospective pilot study of 17 incontinent demented patients and 17 continent patients, matched for age, sex, and total score on the Folstein Mini-Mental Status Exam (MMSE), revealed a striking association between an inability to do a copy task and urinary incontinence. A prospective study confirmed this finding in a sample of 45 patients meeting DSMIII-R diagnostic criteria for dementia, probable Alzheimer's disease. The 17 incontinent patients did not differ from the 28 continent patients in age, sex distribution, or total score on the MMSE. However, the incontinent subjects scored significantly lower on a cube copying task. Qualitative analysis revealed that the drawings by incontinent patients showed features comparable with those observed in the drawings by patients with right-sided parietal lesions, in particular, poor representation of perspective and spatial orientation. Further investigation of the relationship between copying performance and incontinence may have implications for understanding the cortical mechanisms of urinary continence. The present results also underscore the limitations of the MMSE as a measure of dementia severity and suggest there are areas of cognitive ability which are inadequately assessed by MMSE but which may be of major important in understanding the loss of functional skills in the dementing patient.

The release bandwagon.

The essay below, published in the Dr. Whatsisname column in the June 1959 issue of Mental Hospitals, takes a wry look at the wholesale discharge of patients from mental hospitals following the introduction of the new drugs. (See "The New Drugs (Chlorpromazine & Reserpine): Administrative Aspects" on page 327 and Dr. Robert Cancro's commentary and analysis on page 333.) The Dr. Whatsisname column appeared regularly in the journal for almost 14 years before it was discontinued in 1970 and the identity of its author formally revealed: Henry A. Davidson, M.D., a hospital administrator in New Jersey. Washington artist Ralph Robinson drew the cartoons.

The Community Adaptive Planning Assessment: a clinical tool for documenting future planning with clients.

OBJECTIVES: The objectives of this article are to (a) identify features needed in a clinical tool in order to organize collaborative planning for the future between therapist and client; (b) describe the structure and procedures for use of the Community Adaptive Planning Assessment (CAPA), which was developed to meet these needs; (c) summarize research on the usability, trustworthiness, and clinical effectiveness of the CAPA; and (d) consider future work to further evaluate qualitative tools like the CAPA for clinical and research purposes. METHOD: Initial and revised versions of the CAPA were evaluated through several studies. Usability was examined through questionnaires completed by therapists who used the CAPA in acute care, rehabilitation, home health, and community programs with a total of 105 clients who had a variety of acute and chronic disabilities. Trustworthiness was evaluated through comparison of information gathered from 21 clients with that from their family members. Clinical effectiveness was evaluated for discharge planning through content analysis of community outcomes of goals and plans established before discharge. RESULTS: Initial studies indicate that the CAPA has sound usability, trustworthiness, and clinical effectiveness for a variety of service delivery systems and with a variety of clients when used by experienced therapists. Findings support use of these three criteria for evaluation of tools designed to document qualitative consultation-based practice. CONCLUSIONS: Results are related to broader issues in the profession, including a need for further study of collaborative planning for the future between clients and therapists, ways in which qualitative aspects of practice can be documented efficiently, ways in which outcomes of consultation-based practice can be evaluated, and establishment of criteria for evaluation of emerging qualitative assessments and intervention tools.

Continuity and change: past experience as adaptive repertoire in occupational adaptation.

Narratives are gaining recognition as important ways occupational therapists and other clinicians can think about the life stories of clients. The purpose of this article is to examine a conceptualization of how changes from one chapter to another occur in life stories, using the metaphor of an adaptive repertoire, and to consider how this notion can be useful in helping clients maintain continuity and a coherent life story in times of change. Three premises based on the concept of adaptation address (a) configurations of occupational forms embedded in particular local worlds, (b) cumulative development of an adaptive repertoire that allows one to perform both competently and appropriately, and (c) adaptive transitions and application of one's repertoire to new circumstances. Implications for research and clinical practice in occupational therapy also are examined.

Incontinence in institutions: costs and contributing factors.

OBJECTIVES: To determine the relative independent contributions of mobility and mental function to the prevalence rate of incontinence in a long-term care hospital and to establish the baseline prevalence rate and cost of incontinence before implementation of a continence program. DESIGN: Prevalence survey. SETTING: Long-term care hospital. PARTICIPANTS: All 457 inpatients (mean age of men 73.6 years, of women 73.8 years) who met the defined criteria for degree of urinary and fecal incontinence, mobility and mental function. Of the 447 questionnaires that were returned 12 were incomplete. MAIN OUTCOME MEASURES: Degree of urinary and fecal incontinence and costs of incontinence as measured by nursing time spent dealing with incontinent patients, laundry and incontinence supplies. RESULTS: The prevalence rate of urinary incontinence was 62%, fecal incontinence 46% and combined incontinence 44%. The mean time spent each day dealing with incontinence was 52.5 minutes per patient. The total annual cost of incontinence per patient was $9771. Mobility and mental function were independent predictors of frequency of urinary and fecal incontinence. Frequency of incontinent events was the strongest predictor of quantity of linen soiled, but immobility was the strongest predictor of nursing time spent dealing with incontinence. CONCLUSIONS: The prevalence rate of urinary incontinence depends on patient characteristics and the definition of incontinence. A management approach to incontinence could lower laundry and supply costs, and improvements in mobility could reduce nursing time spent dealing with incontinence.

Perceived control and acceptance of the decision to enter a nursing home as predictors of adjustment.

A longitudinal study of newly admitted nursing home residents examined the effects of perceived control over the relocation decision and acceptance of the relocation in general as determinants of changes in functional health and morale. Perceived control had positive effects on health during the first month of residency but negative effects on health and morale between the second and fourth months. On the other hand, acceptance had positive effects on both health and morale between the second and fourth months. Perceived control over the relocation process appears to have short-term benefits but long-term costs, whereas acceptance appears to be a separate and important coping function.

VMA excretion in patients with pheochromocytoma.

Studies in 20 patients, and a reanalysis of previously published data demonstrate that there is a significant linear relationship between the rate of urinary excretion of 3-methoxy-4-hydroxymandelic acid and the size of a pheochromocytoma. This relationship is most significantly demonstrated in a small group of patients with bilateral adrenal disease as part of the MEN II syndrome. Since not all pheochromocytomas are accurately localized preoperatively and significant numbers can be bilateral or extra-adrenal, this predictive index of tumor size has useful surgical implications. An obvious discrepancy between a prediction of size and operative findings should alert the surgeon to a more thorough search of the opposite adrenal and, indeed, all extra-adrenal paraganglionic sites for other secreting tumor tissue.

Intravenous glucose, aminoacids, and fat in the postoperative period. A controlled evaluation of each substrate.

The metabolic effects of hypocaloric (2-51 MJ), equicalorific quantities of intravenous glucose, crystalline aminoacids, and soyabean emulsion were comapred with those of fasting in 4 groups of male patients (closely matched for age, weight, and fat-free mass) on the day of vagotomy and pylorplasty and on the fast 3 postoperative day. Patients given glucose alone excreted less nitrogen than the fasting patients but nitrogen sparing was greatest in the group given aminoacids alone. There was no evidence of any nitrogen sparing when intravenous fat was the source of energy. There was no difference in blood glucose, free fatty acids, and insulin concentrations among the groups. Ketone-body concentrations rose in the fasting and fat-fed groups but remained low in the groups who received glucose or aminoacids. This study indicates that, in the short term, the increased preservation of protein achieved by the infusion of aminoacids compared with that produced by the traditional infusion of glucose does not warrant the extra cost involved.