Identifying dementia in Down syndrome with the Severe Impairment Battery, Brief Praxis Test and Dementia Scale for People with Learning Disabilities.

BACKGROUND: Individuals with Down syndrome (DS) are at high risk for dementia, specifically Alzheimer's disease. However, many measures regularly used for the detection of dementia in the general population are not suitable for individuals with DS due in part to floor effects. Some measures, including the Severe Impairment Battery (SIB), Brief Praxis Test (BPT) and Dementia Scale for People with Learning Disabilities (DLD), have been used in clinical trials and other research with this population. Validity research is limited, particularly regarding the use of such tools for detection of prodromal dementia in the DS population. The current project presents baseline cross-sectional SIB, BPT and DLD performance in order to characterise their predictive utility in discriminating normal cognition, possible dementia and probable dementia in adult DS. METHOD: Baseline SIB, BPT and DLD performances from 100 individuals (no dementia = 68, possible dementia = 16 & probable dementia = 16) were examined from a longitudinal cohort of aging individuals with DS. Receiver operating characteristic curves investigated the accuracy of these measures in relation to consensus dementia diagnoses, diagnoses which demonstrated high percent agreement with the examining neurologist's independent diagnostic impression. RESULTS: The SIB and BPT exhibited fair discrimination ability for differentiating no/possible versus probable dementia [area under the curve (AUC) = 0.61 and 0.66, respectively]. The DLD exhibited good discrimination ability for differentiating no versus possible/probable dementia (AUC = 0.75) and further demonstrated better performance of the DLD Cognitive subscale compared with the DLD Social subscale (AUC = 0.77 and 0.67, respectively). CONCLUSIONS: Results suggest that the SIB, BPT and DLD are able to reasonably discriminate consensus dementia diagnoses in individuals with DS, supporting their continued use in the clinical assessment of dementia in DS. The general performance of these measures suggests that further work in the area of test development is needed to improve on the AUCs for dementia status discrimination in this unique population. At present, however, the current findings suggest that the DLD may be the best option for reliable identification of prodromal dementia in this population, reinforcing the importance of including informant behaviour ratings in assessment of cognition for adults with DS.

Incident atrial fibrillation and the risk of fracture in the cardiovascular health study.

In this prospective cohort of 4462 older adults, incident atrial fibrillation (AF) was not statistically significantly associated with subsequent risk of incident fracture. INTRODUCTION: AF is associated with stroke, heart failure, dementia, and death, but its association with fracture is unknown. Therefore, we examined the association of incident AF with the risk of subsequent fracture in the Cardiovascular Health Study (CHS) cohort. METHODS: Of the CHS participants aged ≥65 years, 4462 were followed between 1991 and 2009, mean follow-up 8.8 years. Incident AF was identified by annual study electrocardiogram (ECG), hospital discharge diagnosis codes, or Medicare claims. Fractures of the hip, distal forearm, humerus, or pelvis were identified using hospital discharge diagnosis codes or Medicare claims. We used Cox proportional hazard models to estimate hazard ratios (HRs) and 95 % confidence intervals (CIs) for the association between incident AF (time-varying) and the risk of subsequent fracture. We also evaluated whether AF was associated with risk of sustaining a fall. RESULTS: Crude incident fracture rate was 22.9 per 1000 person-years in participants with AF and 17.7 per 1000 person-years in participants without AF. Individuals with incident AF were not at significantly higher risk of hip fracture (adjusted HR = 1.09, 95 % CI 0.83-1.42) or fracture at any selected site (adjusted HR = 0.97, 95 % CI 0.77-1.22) or risk of sustaining a fall (adjusted HR = 1.00, 95 % CI = 0.87-1.16) compared with those without AF. CONCLUSION: In this cohort of older, community-dwelling adults, incident AF was not shown to be associated with falls or hip or other fractures.

Mind-body and the future of psychiatry.

Philosophical perspectives are deeply relevant to psychiatric theorization, investigation, and practice. There is no better instance of this than the perennially vexing mind-body problem. This essay eschews reductionist, dualist, and identity-theory attempts to resolve this problem, and offers an ontology--"monistic dual-aspect interactionism"--for the biopsychosocial model. The profound clinical, scientific, and moral consequences of positions on the mind-body relation are examined. I prescribe a radically biological cure for psychiatry's--and all medicine's--chronic dogmatism and fragmentation.

Pitfalls of a one-sided image of science: Adolf Grünbaum's Foundations of Psychoanalysis.

Adolf Grünbaum's (1984) The Foundations of Psychoanalysis has received extensive attention in psychoanalytic and philosophical circles. Aspects of Grünbaum's argument are reviewed and criticized. While his volume is an important contribution to the epistemological assessment of psychoanalysis, it reflects serious shortcomings in at least four areas: its treatment of the role of suggestion in the analytic enterprise, its scrutiny of the psychoanalytic genetic method, its appreciation of analytic methodology as actually practiced, and, above all, its predication on a unidimensional, positivistic vision of science. Alternative approaches to the philosophy of psychoanalysis are suggested.

What is "truth"? Some philosophical contributions to psychiatric issues.

Philosophical perspectives, although eminently relevant to clinical investigation and practice, are rarely brought to bear on psychiatric topics. The author attempts to raise professional consciousness of core issues in the philosophy of science by examining the status of truth, theory, and observation in psychiatry. He evaluates prominent approaches to the problem of knowledge, particularly those of the "subjectivists" and "relativists," such as Schafer and Spence, and the "empiricists" and "inductivists," such as the proponents of DSM-III. Drawing on contemporary philosophy of science, the work of William James, and the classical Greek conviction that more truth resides in the middle than at either extreme, the author mediates between these rival points of view.

Mind-body. Monistic dual aspect interactionism.

It is difficult to imagine a more perennially vexing topic to philosophers, scientists, and physicians than the mind-body problem. Recent literature bears out its continued vital interest for psychiatrists. This article briefly recapitulates the major perspectives on the problem, examines the relationship of meaning and mind to psychosocial and biological explanatory programs and to materiality, and promotes a monistic dual aspect interactionist approach to mind and body in health and illness. From this thesis conclusions are drawn in regard to the ultimate possibility of a psychiatric unitary field theory, the question of the autonomy of the psychological and biological explanatory programs, and the identity of the psychiatrist.

Determinism, possibility, and ethics.

This essay reexamines the age-old "determinism-free will" problem from a psychoanalytic perspective. The first section recapitulates the author's (1985) earlier argument on the nature of causation in psychoanalysis; the second part examines the compatibility of determinism and freedom; and the final section looks at the ethical ramifications of the issues at hand. The author exposits his adherence to universal determinism and attempts to answer the question, "What sort of possibility and ethics are permitted in a deterministic universe?"