Cognitive and motor assessment in autopsy-proven corticobasal degeneration.

OBJECTIVE: To investigate the clinical features of autopsy-proven corticobasal degeneration (CBD). METHODS: We evaluated symptoms, signs, and neuropsychological deficits longitudinally in 15 patients with autopsy-proven CBD and related these observations directly to the neuroanatomic distribution of disease. RESULTS: At presentation, a specific pattern of cognitive impairment was evident, whereas an extrapyramidal motor abnormality was present in less than half of the patients. Follow-up examination revealed persistent impairment of apraxia and executive functioning, worsening language performance, and preserved memory. The motor disorder emerged and worsened as the condition progressed. Statistical analysis associated cognitive deficits with tau-immunoreactive pathology that is significantly more prominent in frontal and parietal cortices and the basal ganglia than temporal neocortex and the hippocampus. CONCLUSION: The clinical diagnosis of corticobasal degeneration should depend on a specific pattern of impaired cognition as well as an extrapyramidal motor disorder, reflecting the neuroanatomic distribution of disease in frontal and parietal cortices and the basal ganglia.

The relationship between caregivers' global ratings of Alzheimer's disease patients' quality of life, disease severity, and the caregiving experience.

OBJECTIVES: To compare caregivers' ratings of Alzheimer's disease (AD) patients' global quality of life (QOL) using direct assessments and substituted judgments, and to identify qualities of the patients and their caregivers that are associated with these QOL assessments. DESIGN: Cross-sectional interviews. SETTING: A university-based Memory Disorders Clinic. PARTICIPANTS: Forty primary caregivers of AD patients. MEASUREMENTS: Direct scaling of overall quality of life (poor, fair, good, very good, or excellent) and measures of dementia severity, the caregiving experience, and patient and caregiver demographics. RESULTS: The majority of patients had mild (n = 20) or moderate (n = 11) AD. Caregivers' direct assessments of patient QOL were poor (5%, n = 2), fair (28%, n = 11), good (40%, n = 16), very good (20%, n = 8), and excellent (8%, n = 3). Twenty-one (52.5%) of the caregivers rated the patient's QOL the same as they thought the patient would; 12 (30.0%) rated the patient's QOL worse; and seven (17.5%) rated the patient's QOL better. Agreement between the two ratings was fair to moderate. Bivariate analyses showed that lower ratings of caregivers' direct assessments of patient QOL were associated with decreasing ratings of patient mental health and increasing dementia severity, caregiver burden, and caregiver depression. Multivariate models showed burden to be the significant predictor of caregivers' rating of patient QOL and the subscale measuring the caregivers' distress at controlling patient behavior had the strongest association with QOL. Lower ratings of substituted judgment assessments of patient QOL were associated with lower caregiver ratings of the patient's mental health. CONCLUSIONS: Nearly one-half of the caregivers of patients with predominantly mild to moderate AD assess a patient's QOL differently than they believe the patient would. Dementia severity and the caregiver's experiences of depression and burden negatively affect caregivers' assessments of QOL. These results provide a compelling reason why clinicians should take the time to screen for and address caregiver depression and burden and problematic patient behaviors.

A systematic approach to risk stratification and intervention within a managed care environment improves diabetes outcomes and patient satisfaction.

OBJECTIVE: To determine whether a comprehensive diabetes management program that included risk stratification and social marketing would improve clinical outcomes and patient satisfaction within a managed care organization (MCO). RESEARCH DESIGN AND METHODS: The 12-month prospective trial was conducted at primary care clinics within a MCO and involved 370 adults with diabetes. Measurements included 1) the frequency of dilated eye and foot examinations, microalbuminuria assessment, blood pressure measurement, lipid profile, and HbA(1c) measurement; 2) changes in blood pressure, lipid levels, and HbA(1c) levels; and 3) changes in patient satisfaction. RESULTS: Complete data are reported for the 193 patients who had been enrolled for 12 months; life table analysis is reported for all patients who remained enrolled at the study's end as well as for a comparative control group of 623 patients. For the 193 patients for whom 12-month data were available, the number of patients in the low-risk category (HbA(1c) <7%) increased by 51.1%. A total of 97.4% of patients with an HbA(1c) >8% at baseline had a change in treatment regimen. Patients at the highest risk for coronary heart disease (LDL >130 mg/dl) decreased from 25.4% at baseline to 20.2%. Patients with a blood pressure <130/85 mmHg increased from 23.8 to 44.6%. Of these patients, 63.0% had changes in medication. Patients and providers expressed significant increases in satisfaction with the program. CONCLUSIONS: The program was successful in initiating the recommended changes in the diabetic therapeutic regimen, resulting in improved glycemic control, increased monitoring/management of diabetic complications, and greater patient and provider satisfaction. These results should have great significance in the design of future programs in MCOs aimed at improving the care of people with diabetes and other chronic diseases.

The burden of chronic hyperglycemia.

Diabetic complications constitute the principal clinical and economic burdens of diabetes. Available evidence indicates that sustained reduction in hyperglycemia (as measured by HbA1c) reduces the incidence of diabetic complications, including microvascular and neurological disease, and will likely reduce the risk of macrovascular disease. In the U.S., targeting interventions to aged and ethnic subpopulations, which are currently receiving suboptimal care, and increasing efforts to lower the average HbA1c concentrations one or two percentage points in people with diabetes would be a more cost-effective goal than aiming for a theoretical HbA1c threshold below which the risk of complications is negligible. Other risk factors for diabetic complications, such as obesity, hypertension, cigarette smoking, and hypercholesterolemia, must also be addressed to reduce the burden of diabetes.

The severe impairment battery: concurrent validity and the assessment of longitudinal change in Alzheimer's disease. The Alzheimer's Disease Cooperative Study.

Measurement of cognitive dysfunction in the early stages of Alzheimer's disease (AD) has been well studied and there are many objective tests in use for this purpose. However, with the exception of clinical rating scales, such as the Clinical Dementia Rating Scale, Global Deterioration Scale, and Functional Assessment Staging, there are few objective measures of cognition in the more advanced stages of AD. Given a renewed interest in potential AD therapies, objective measures of mental functioning are needed to adequately assess change in more advanced AD patients. As part of an effort by the NIA-Alzheimer's Disease Cooperative Study to evaluate new measures of efficacy for their utility in treatment studies, the Severe Impairment Battery (SIB) was examined in a 1-year evaluation of change across a wide range of AD severity. The data suggest that the SIB is a reliable and valid measure of progression, particularly in persons with moderate to severe AD. The SIB may therefore be a useful outcome measure in clinical trials that include patients with more advanced stages of AD.

Performance of the dementia severity rating scale: a caregiver questionnaire for rating severity in Alzheimer disease.

The Dementia Severity Rating Scale (DSRS) is an informant-based, multiple-choice questionnaire that assesses severity from the mildest to the most severe stages in the major functional and cognitive domains affected in Alzheimer disease (AD). The DSRS has good reliability as measured by making repeated observations over short time periods and by comparing caregiver responses to information collected by a physician or an experienced nonphysician research associate. The measure correlates favorably with the Washington University Clinical Dementia Rating scale and with standard cognitive testing measures. The DSRS provides a simple, valid, and sensitive measure of impairment associated with AD. It is ideally suited for multisite collaborative studies and can be implemented with a minimum of staff time and training.

Implementing clinical paths in a managed care environment.

The survival of health care institutions depends upon a delivery system focusing on appropriate use of resources and controlling length of stay while monitoring clinical progress toward identified outcomes. Using a clinical path as a tool for managing resources, research activities, continuous quality improvement, and increased collaborative practice can enhance the professional practice environment and benefit patient care.

The Consortium to Establish a Registry for Alzheimer's Disease (CERAD). Part VI. Family history assessment: a multicenter study of first-degree relatives of Alzheimer's disease probands and nondemented spouse controls.

Although familial factors in Alzheimer's disease (AD) are well established, uniform family-history assessment in genetic and epidemiologic studies of AD is needed to reconcile the divergent estimates of the cumulative risk of this illness among relatives of AD probands. To answer the need, the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) has developed a standardized Family History Assessment of AD to identify the presence of AD, Parkinson's disease (PD), and Down's syndrome (DS) in family members. This paper describes the use of this new assessment instrument in 118 patients with AD (estimated mean age at onset [+/- SD] = 64.5 +/- 7.7 years) and their nondemented spouses who were enrolled in 11 different CERAD sites in the U.S. The first-degree relatives of the probands with AD had a significantly greater cumulative risk (p < 0.005) of AD or primary progressive dementia (24.8%) than did the relatives of spouse controls (15.2%). Furthermore, the cumulative risk for this disorder among female relatives of probands was significantly greater than that among male relatives. There were no differences between the families of probands and controls for the numbers of affected first-degree relatives with PD or DS. This is the first reported multicenter family-history study of AD, and it supports earlier reports of familial factors in AD and indicates a higher risk to female relatives of AD probands. The CERAD Family History Assessment instrument may be useful for further multicenter and epidemiologic studies designed to delineate familial factors associated with AD.

Clinical assessment of adolescents involved in Satanism.

Satanism is a destructive religion that promises power, dominance, and gratification to its practitioners. Unfortunately, some adolescents are seduced by these promises, often because they feel alienated, alone, angry, and desperate. This article explores the psychosocial needs of adolescents that are often met by participation in Satanic worship. Gratification of these needs, when met, may make leaving the cult a difficult and lengthy process. Included is a method for determining the adolescents' level of involvement and an assessment strategy for the therapeutic evaluation process. A brief overview of clinical intervention is also discussed.

Standards for the care of diabetes. Origins, uses and implications for third-party payment.

Standards of care are those principles that define the appropriate environment, process, and procedures necessary for quality medical care and optimal health outcomes. The initial impetus to develop standards of care came from the medical profession when it attempted to define quality of care. More recently, standards defining the medical necessity of diagnostic tests or procedures have been developed at the request of public and private third-party payors. These efforts are the natural outgrowth of two decades of health-care delivery research and technology assessment examining the effectiveness of various medical procedures. This article reviews the development of standards by the medical profession, emphasizing current standard-setting activities of private organizations and the federal government. This study examines the characteristics of a good process for developing credible medical standards to guide patient care and the payment for that care. This study also discusses how the American Diabetes Association used this process in developing standards for care of patients with diabetes mellitus and implementation problems encountered because of coverage policy of public and private health insurer programs.

Deviant adolescent subcultures: assessment strategies and clinical interventions.

Alienation is a contributing factor in adolescents' participation in Satanism, the neo-Nazi skinhead movement, and violent street gangs. Many of their needs are met by gang and/or cult affiliation, including a sense of belonging, self-worth, companionship, and excitement. Emphasizing prevention may minimize deviant subculture involvement, but some adolescents require clinical intervention, ranging from a few outpatient sessions to lengthy inpatient hospitalization. Therapists must be knowledgeable about adolescents' involvement, empathic to their circumstances, and sophisticated in the approach to treatment.