Reality orientation therapy to delay outcomes of progression in patients with dementia. A retrospective study.

OBJECTIVE: To evaluate the impact of continued Reality Orientation Therapy (ROT) in delaying the outcomes of dementia progression. DESIGN: Retrospective study. Data collection was based on review of clinical charts and on telephone interviews performed with patients or primary caregivers. SETTING: Day hospital of the Alzheimer's Disease Unit, Brescia (Italy). SUBJECTS: Seventy-four patients enrolled in at least one cycle of ROT from 1994 to 1998 were studied. INTERVENTIONS: Rehabilitative intervention based on formal ROT. MAIN OUTCOME MEASURES: This study analysed the time to the occurrence of any of the following: cognitive decline on Mini-Mental State Examination scores, urinary incontinence as an index of functional decline, institutionalization, and death. RESULTS: Data on a 30-month period after the first ROT session were analysed. We compared 46 patients (treatment group) who completed from 2 to 10 ROT cycles (corresponding to 8-40 weeks of training; mean = 15.48) with 28 patients (control group) who completed only one ROT cycle (4 weeks). Treatment group showed higher estimated survival rates than control group on cognitive decline (p = 0.022) and institutionalization (p = 0.002). The relative risks for cognitive decline and institutionalization in the control group compared with treatment group were 0.60 (p = 0.014), and 0.42 (p = 0.021), respectively. CONCLUSIONS: Continued ROT classes during the early to middle stages of dementia may delay nursing home placement and slow down the progression of cognitive decline.

Hostility as a feature of elderly suicidal ideators.

Literature suggests that suicidal feelings are relatively rare in mentally healthy older adults. This research investigated the presence of death or suicidal ideation in a group of home-dwelling elderly people (N = 611, M age = 75.7 yr., SD = 7.2), taking into account their psychopathological profiles assessed by means of the Brief Symptom Inventory. Suicidality was investigated by the Italian translation of the 1974 questions from Paykel, Myers, Lindenthal, and Tanner. Elderly with death or suicidal ideation manifested depressive and anxious symptoms on the Brief Symptom Inventory. This psychopathological profile, which has been reported for these subjects in various contributions to the literature, was also characterized by the presence of hostility. The correlation with higher scores on the hostility scale is difficult to interpret, although these feelings are often accompanied by failure to control impulses, which is an essential characteristic in suicidal behaviour.

Death ideation and its correlates: survey of an over-65-year-old population.

The presence of dissatisfaction with life or thoughts of death or suicide has been variously surveyed in adolescent samples and in the general population, but there is a paucity of research on the elderly. The aim of this study was to assess, in an elderly community-dwelling population: a) the prevalence of death and/or suicidal feelings and thoughts and any attempted suicides; and b) factors associated with these experiences. A total of 611 over-65-year-old subjects were interviewed at home. Seventeen percent of the total (F:M = almost 2:1) responded affirmatively to at least one of the questions on suicidality. Elderly people reporting suicidal feelings presented markedly higher levels of physical and psychological distress, such as depression, anxiety, and hostility. Results indirectly confirm that depressive symptomatology is not adequately treated. Greater attention is warranted in psychological evaluation of the elderly to take into account those risk factors that, if identified and managed, could reduce the frequency of suicidal thoughts and, probably, associated actions.

Alternative medicine in a sample of 655 community-dwelling elderly.

OBJECTIVE: Use and satisfaction with herbal/homeopathic remedies, acupuncture and relaxation techniques were examined in an Italian elderly population. METHODS: Data were collected as part of a survey on an elderly population, conducted in 1996--1997 in the urban centre of Padua, Italy. A total of 1362 elderly received a letter inviting them to participate and to accept the visit of an interviewer at home. Of these, 212 were unable to do so for insurmountable reasons and 666 gave consent to take part in the study with a response rate of 65%. Eleven participants were excluded from the study because cognitively impaired. RESULTS: Among the 655 respondents, overall use of at least one alternative medicine was 29.5%. Herbs/phytotherapeutics (47%) and acupuncture (34%) were the most frequently cited therapies. The use of alternative medical practices seems rather widespread among the elderly population in Padua, especially among females with depressive symptoms, pain and discomfort, but not suffering from chronic somatic disease. A percentage of 3.7% of the sample used exclusively alternative medicines; those subjects seemed to be younger, less likely to be physically ill and to report functional disorders and chronic somatic disease. CONCLUSION: Alternative medicines seem to have a complementary role for the elderly with self-perceived psychological symptomatology or disorders, particularly of depressive nature. They may constitute an attempt at self-treatment, probably concealing the difficulties encountered by the elderly subjects in seeking specialist advice for these problems.

Influence of cognitive status on the sexual life of 352 elderly Italians aged 65-105 years.

BACKGROUND: Various factors are considered to influence sexual behavior in the elderly, but the role played by preservation of adequate cognitive functioning has not been adequately explored. OBJECTIVE: The aim of this research, conducted on 352 older adults aged between 65 and 105 years, was to identify the specific role played by cognitive functioning in sexual activity and sexual interest in the elderly. METHODS: The data were collected from elderly people attending the surgeries of 21 general practitioners in the city of Padua (Italy). Analysis of sexual functioning was based on two items, from the LEIPAD questionnaire: 'Are you interested in sex?' and 'Do you have sexual relations?'. Subjects cognitive status was assessed objectively through the Mini Mental State Examination (MMSE) and subjectively by the LEIPAD subscale on cognitive functioning. RESULTS: Subjects who were sexually active and interested in sex were more highly represented among the married elderly. The elderly who reported being active and interested in sex were significantly younger and had a significantly superior educational level and MMSE score. Mean scores for cognitive functioning and all quality-of-life indicators were in general significantly better for the active and interested. Univariate logistic regression analysis indicated that a higher MMSE score and cognitive functioning score influenced the maintenance of sexual interest. CONCLUSIONS: One third of the subjects reported being still sexually active and 40% being still interested in sex. This study seems to suggest that a significant role may be played by cognitive functioning in the maintenance of sexual interest in the elderly, especially older females in whom this dimension is evidently linked to far more diversified experiences than their male peers.

The role of psychopathology and suicidal intention in predicting suicide risk: a longitudinal study.

OBJECTIVE: In this study, we describe psychological symptoms, any relationship with suicidal intention in a sample of subjects recently attempting suicide and the predictive value of this association in later completed suicide. METHODS: An assessment was made of 467 suicidological consultations carried out by the Suicidology Unit of the Department of Neurology and Psychiatry, University of Padua, on 421 patients admitted to hospital following attempted suicide in the 5-year period 1990-1994. Suicidal intention was appraised by the Intent Score Scale (ISS). Suicide mortality was assessed after a mean follow-up period of 3.5 years. RESULTS: Psychiatric evaluation was completely negative in only 8% of cases. The most commonly identified symptom was depressed mood (79% of cases, 22% severe depression), followed by anxiety (43% of cases, 32% severe anxiety). From the study, it emerged that psychopathology seemed to influence suicidal intent, where this was characterized by severe depression. Anxiety and other symptoms appeared to have a secondary role. Assessments of suicidal intent showed that intention heightened as the number of symptoms increased. The symptom 'anxiety' did not prove to have a significant bearing on assessment of the seriousness of suicidal intention, whereas severely depressed mood did. The total number of subsequent suicide victims was 5.5%. During consultation relating to the index parasuicide, these subjects did not manifest a discriminate psychopathological profile (the only distinguishing characteristic was anxiety, which was less frequently identified in suicide victims), but did present a more positive personal and family psychiatric history. CONCLUSIONS: In subjects who had recently attempted suicide, the psychopathological profile appeared to be related to suicidal intent, where this was characterized by severe depression. Anxiety and other symptoms seemed to have a secondary role. Nonetheless, both total scores and subscores should be taken into consideration when assessing suicidal intention through the ISS. The psychopathological profile and ISS score following attempted suicide do not appear to permit prediction, in the medium to long term, of subsequent completed suicide.

Community care for patients with Alzheimer's disease and non-demented elderly people: use and satisfaction with services and unmet needs in family caregivers.

OBJECTIVE: This study measures and compares use of and satisfaction with medical and social services in addition to subjectively perceived needs of family supporters of patients with probable or possible Alzheimer's disease (AD) and family supporters of non-demented elderly people. Differences in judgement of services within the subpopulation of families of AD patients are also assessed by gender and burden level. METHODS: The main family supporters of 60 community-dwelling elderly (aged over 65) with Alzheimer's disease and of 60 age- and sex-matched controls were tested with a detailed questionnaire on use and satisfaction with services, any unmet needs and kinds of intervention perceived to be helpful. RESULTS: Supporters of elderly people with AD were significantly more involved in providing care than supporters of non-demented people. Judgement on the health, social relations and financial status of their families was significantly worse in AD supporters than in supporters of non-demented elderly people. Although the former made more use of available health and social services than the control population, they did appear to make little use of such services, not only because of lack of information but also for logistic reasons or because they would prefer a service with more specifically trained operators or more tailored intervention. AD family supporters would like to receive more information and support from their general practitioner, which confirms the importance of this figure in management of this pathology. They were less satisfied with the care provided than the control population, particularly those with a moderate-high burden. Irrespective of burden level, they also expressed a need for financial and psychological support and adequate intervention schemes, especially within the home. These should be provided by specially trained personnel and be tailored to specifically manage the individual patient's problems, especially in relation to behavioural disorders. This would help alleviate caregiver burden and allow patients to continue to be managed at home.

LEIPAD, an internationally applicable instrument to assess quality of life in the elderly.

A questionnaire to assess quality of life in the elderly was developed under the auspices of the European office of the World Health Organization. Stages in construction of the instrument, which was designed for international application, particularly at the primary level, are described. The latest version of the questionnaire is composed of 49 self-assessment item, 31 of which can be grouped into 7 subscales: Physical Function, Self-Care, Depression and Anxiety, Cognitive Functioning, Sexual Functioning, and Life Satisfaction. The remaining 18 items serve as moderators for assessing the influence of social desirability factors and personality characteristics on the individual scores for the 7 core instrument subscales. The questionnaire has been administered to 586 individuals aged 65 years and over recruited in communities in Italy (Padua and Brescia), the Netherlands (Leiden), and Finland (Helsinki). The main psychometric characteristics of the instrument, together with its concurrent validity with the Rotterdam Questionnaire, are illustrated.

Quality of life and longevity: a study of centenarians.

OBJECTIVE: Interest in centenarians has focused on two particular aspects: the antecedents of extreme old age and the psychophysical well-being of the very old. Our study deals with the latter aspect and aims to assess the quality of life of Italian centenarians. METHOD: Using data collected using two questionnaires designed to investigate quality of life in elderly people, three groups of 38 elderly subjects were compared: centenarians and subjects aged between 75 and 85 years and 86 and 99 years. RESULTS: The centenarians complained less spontaneously about their health (maintained in part by medical treatments), but declared having greater functional disability. Their cognitive function appears to be reasonably well preserved and they have lower scores for anxiety and depression than the subjects in the two younger groups. They consider themselves religious, satisfied with their financial situation but no longer interested in sex or involved in recreational activities. They report greater satisfaction with life and with social and family relations than do less elderly individuals. CONCLUSIONS: The centenarians we interviewed seem to be well adapted to their lives and to maintain a more positive attitude than the subjects in the two younger groups.

Lower suicide rates associated with a Tele-Help/Tele-Check service for the elderly at home.

OBJECTIVE: The authors' goal was to determine the impact on suicidal behavior of Tele-Help/Tele-Check, a telephone service designed to provide elderly people with home assistance. Tele-Help is an alarm system that the client can activate to call for help; in Tele-Check the client is contacted about twice a week for assessment of needs and for emotional support. METHOD: The authors determined the number of suicides among 12,135 elderly subjects who were connected to the Tele-Help/Tele-Check service in the Veneto region of Italy from Jan. 1, 1988, to Dec. 31, 1991, and compared it with the suicide rate for the general population in the Veneto region. RESULTS: Only one death by suicide was found in the elderly subjects connected to Tele-Help/Tele-Check, compared with the expected number of 7.44 for the general population (standardized mortality ratio = 13.44%). CONCLUSIONS: Since many of the traditional risk factors for suicide were concentrated in the elderly subjects studied, the Tele-Help/Tele-Check service appears to provide support of great interest for the prevention of suicide in the elderly.

Reality orientation therapy in Alzheimer disease: useful or not? A controlled study.

The aim of this controlled study was to evaluate the effects of a long-term program of formal didactic group therapy [class reality orientation therapy (ROT)] in Alzheimer disease. The study was conducted in the day hospital of an Alzheimer Dementia Research and Care Unit (Brescia, Italy), a multidisciplinary care center providing diagnostic evaluation and treatment for elderly patients with cognitive impairment. The criteria for the inclusion of patients in the study were mild to moderate cognitive impairment [Mini Mental Status Examination (MMSE) between 11 and 24/30] and absence of major aphasia, blindness, and overt behavioral disturbances such as wandering or agitation. Sixteen patients constituted the experimental group and 12 the control group. The last cognitive, functional, and affective evaluation in the experimental and control group was performed 8.2 and 8.5 months after baseline assessment, respectively. The experimental group had repeated cycles of 1-month ROT classes, and 5-7 weeks was allowed between each cycle. Differential change for MMSE score between the two groups was significant. In the experimental group, there was mild improvement in MMSE score (0.68 point) at the last assessment, whereas the control group declined (-2.58 points). This treatment effect on MMSE score (3.27 points) was controlled for potential confounders in a multiple regression analysis. Adjusted treatment effect, including age, education, baseline MMSE, disease duration, disease severity, number of diseases other than Alzheimer, and time elapsing from baseline to last assessment, was very slightly lower: 3.12. In the experimental group, treatment effect was evaluated by comparing ROT cycle changes and resting period changes. A clearly significant treatment effect was found for MMSE and verbal fluency.

Assessment of quality of life in the elderly assisted at home through a Tele-Check service.

This study evaluates the effects of a Tele-check/Tele-emergency service on the quality of life in the elderly. Through telephone interviews a questionnaire has been repeatedly administered to explore various psychological, somatic, and social aspects in a random sample of 574 subjects aged 65 years and over (mean = 76.8 years). The findings suggest that the elderly helped by the service (in its 'control' functioning) make less demands on health facilities (GPs visits, number of days in hospital) as compared to controls. Implications are presented and discussed.