Is home health technology adequate for proactive self-care?

OBJECTIVE: To understand whether home health technology in the market and in development can satisfy the needs of patients and their non-professional caregivers for proactive support in managing health and chronic conditions in the home. METHODS: A panel of clinical providers and technology researchers was assembled to examine whether home health technology addresses consumer-defined requirements for self-care devices. A lexicon of home care and self-care technology terms was then created. A global survey of home health technology for patients with heart disease and dementia was conducted. The 254 items identified were categorized by conditions treated, primary user, function, and purpose. A focus group of patients and caregivers was convened to describe their expectations of self-care technology. Items identified in the database were then assessed for these attributes. RESULTS: Patients and family caregivers indicated a need for intelligent self-care technology which supports early diagnosis of health changes, intervention enablement, and improvement of communication quality among patients and the health care system. Of these, only intervention enablement was commonly found in the home health technology items identified. CONCLUSIONS: An opportunity exists to meet consumer self-care needs through increased research and development in intelligent self-care technology.

Assessing the competence of persons with Alzheimer's disease in providing informed consent for participation in research.

OBJECTIVE: The capacity of persons with Alzheimer's disease or other neuropsychiatric disorders for giving consent to participate in research has come under increasing scrutiny. While instruments for measuring abilities related to capacity have been developed, how they should be used to categorize subjects as capable or incapable is not clear. A criterion validation study was carried out to help address this question. METHOD: The authors measured the ability of 37 subjects with mild-to-moderate Alzheimer's disease and 15 elderly comparison subjects to provide consent for participation in a hypothetical clinical trial. Using the judgment of three experts as the criterion standard, the authors performed a receiver operator characteristic analysis for the capacity ability measures from the MacArthur Competence Assessment Tool-Clinical Research VERSION: The results were compared with categorizations of capacity status that were based on normative values. RESULTS: While most comparison subjects scored perfectly on all measures of the competence assessment tool, the majority of the group with Alzheimer's disease showed significant decision-making impairment. Thresholds based on normative values resulted in 84% (N=31) of the Alzheimer's disease subjects being rated as incapable on at least one ability; thresholds based on expert judgment resulted in 62% (N=23) failing to meet cutoff scores on at least one ability. CONCLUSIONS: Even relatively mild Alzheimer's disease significantly impairs consent-giving capacity. But differentiating capable from incapable subjects remains an issue despite the aid of standardized tools. More research is needed to understand the relationship between subject factors (performance on ability measures) and categorical judgments about their capacity.

Cross-discipline disparities in perceptions of mental disorders in a long-term care facility.

OBJECTIVES: This study compared prevalence rates of mental disorders in a single long-term care facility as perceived by three professional disciplines and compared professionals' perceptions with two standardized measures of psychopathology. DESIGN: Comparison of (1) prospective standardized psychiatric evaluations performed by psychiatrists, (2) chart reviews of mental disorders as documented by primary care physicians, and (3) interviews of nurses. SETTING: The residential health care facility at Monroe Community Hospital in Rochester, New York. PARTICIPANTS: A 20% random sample of adult residents, stratified by ward (n = 80). MEASUREMENTS: Prevalence rates of psychopathology as determined by each data collection method: psychiatric diagnoses as determined by psychiatrists and primary care physicians, the Brief Psychiatric Rating Scale, and the Psychogeriatric Dependency Rating Scale. RESULTS: Prevalence rates of psychopathology ranged from 60 to 91% across discipline-specific data collection methods. Using psychiatrists' diagnoses as the benchmark, primary care physicians and nurses underestimated the prevalence of mental disorders, particularly organic mental disorders. All disciplines agreed on the presence of personality and developmental disorders. The Brief Psychiatric Rating Scale and Psychogeriatric Dependency Rating Scale validated perceptions of psychopathology by psychiatrists and nurses, but not by primary care physicians' chart diagnoses. CONCLUSION: Disparities in perceptions of mental disorders across disciplines pose a threat to patient care and suggest a need for more reliable incorporation of mental health expertise in the long-term care setting.

Lack of carbamazepine toxicity in frail nursing home patients: a controlled study.

OBJECTIVE: To assess the effects of carbamazepine and placebo on measures of toxicity in frail nursing home patients. DESIGN: A nonrandomized, double-blind, placebo-controlled crossover study. SETTING: Two nursing homes in Rochester, New York. PARTICIPANTS: Twenty-five subjects (mean age 84.5 years) with dementia. INTERVENTION: Carbamazepine and placebo during two 5-week periods separated by a 2-week washout. The modal dose for each patient was 300 mg/day. MEASUREMENTS: Adverse experiences, comorbid events, and physical signs and symptoms were assessed continuously, and laboratory data were examined at the beginning and end of each treatment period. RESULTS: One subject died with a pneumonia (and elevated white blood cell count), and one subject developed probable carbamazepine-induced tics. There was a minimal drop in hematocrit and a slight elevation of liver enzymes, none of which was clinically significant. There was otherwise no excess of adversity or comorbid events on carbamazepine versus placebo, and there was no change in electrolytes or other laboratory measures. CONCLUSION: The findings indicate that carbamazepine in this dose range was well tolerated for the 5-week treatment period in this frail sample. These data supplement the literature regarding carbamazepine toxicity, which is devoid of controlled studies in older subjects.

Low-dose acetylsalicylic acid use and hemoglobin levels. Effects in a primary care population.

OBJECTIVE: To determine the prevalence of acetylsalicylic acid therapy and effect of the drug on hemoglobin concentration over time. DESIGN: Retrospective, observational study. SETTING: Primary care population in a university-affiliated family medicine clinic. PATIENTS: A population-based sample of 80 patients receiving low-dose ASA for secondary prevention of cardiovascular disease was studied. Of 84 patients receiving the drug after a cardiovascular problem, four were excluded: one man died of a recurrent stroke during the study; the file of a second man was unavailable; another man developed a bleeding ulcer; and one woman had been taking ASA for only 1 month when the data were collated. MAIN OUTCOME MEASURES: Demographic variables of patients taking low-dose ASA, duration of ASA use, and two successive measures of hemoglobin level. RESULTS: The frequency of ASA administration was 7.7% for men aged 60 and older and 2.9% for women. Women had no significant change in hemoglobin levels, while men had a mean loss of 0.472 g/dL (95% confidence interval, .198 to .746; P = .009). For the study population as a whole (80 patients), the average decline was 0.294 g/dL (95% confidence interval, .039 to .549; P = .029). CONCLUSIONS: Although the clinical significance of these findings is uncertain, they suggest the need for a prospective investigation of the influence of low-dose ASA on hemoglobin levels.

Carbamazepine treatment of agitation in nursing home patients with dementia: a preliminary study.

OBJECTIVE: To determine the effects of carbamazepine versus placebo on ratings of behavior in agitated nursing home patients with dementia. DESIGN: Nonrandomized, placebo-controlled, crossover trial conducted in 25 patients in two nursing homes. INTERVENTION: Carbamazepine and placebo were administered during two 5-week periods separated by a 2-week washout. The carbamazepine dose was determined for each patient by a nonblinded physician who did not participate in ratings (modal dose 300 mg/day). MEASUREMENTS: The primary outcome measures were Brief Psychiatric Rating Scale scores and Clinical Global Impression of Change, rated by blind observers. Secondary measures of behavior, adversity, cognition, and functional status were also included. MAIN RESULTS: Median total Brief Psychiatric Rating Scale score decreased 7 points on carbamazepine versus 3 on placebo (P = 0.03). Sixteen subjects were rated as improved globally on carbamazepine versus four on placebo (P = 0.001). Secondary measures of behavior showed similar changes at significant or suggestive (P < 0.10) levels. One subject developed carbamazepine-induced tics, and one died with a pneumonia. There was minimal other adversity. CONCLUSION: This preliminary study suggests that carbamazepine in low doses can reduce agitated behaviors in some patients, with limited adversity resulting. Further research is required to confirm and extend this finding before it can be considered routine clinical practice.

The management of other psychiatric states. Hallucinations, delusions, and other disturbances.

The behavioral disturbances that are most common in Alzheimer's disease are not those directly associated with the core characteristics of the disease; however, they often cause the most difficult problems of management. These disturbances include agitation, hallucinations, and delusions. This article reviews their prevalence, etiology, differential diagnosis, and management.

Mental disorders in the nursing home: another perspective.

OBJECTIVE: Many studies of the prevalence of mental disorders among residents of long-term care facilities have had substantial methodological shortcomings. This study was conducted to replicate a previous well-designed study and to examine additional characteristics of nursing home residents. METHOD: Randomly selected residents (N = 80) in a public long-term care facility were evaluated by a psychiatric team using DSM-III-R criteria and quantitative assessments of behavior and cognitive status. RESULTS: Of the 80 subjects, 91% had at least one psychiatric diagnosis and at least one behavioral problem; 50% had four or more behavioral problems. In addition, 29% had received psychiatric care before admission, and 61% received psychiatric care after admission. CONCLUSIONS: These findings replicate those of the few prior studies that used analogous research techniques, but those previous studies were conducted in private, intermediate-care institutions whose residents had different demographic characteristics. The mental health needs of these residents are substantial and should be addressed by the medical community and the nursing home industry.

Carbamazepine-induced tics.

Although a variety of dyskinesias are known to develop during anticonvulsant therapy, carbamazepine-induced tics are rarely recognized. We report three patients with an underlying movement disorder (Huntington's disease, tardive dyskinesia, and Tourette's syndrome) who experienced the onset or exacerbation of tics after the introduction of carbamazepine. These cases confirm the phenomenon of carbamazepine-induced tics and suggest that basal ganglia neuropathology may be an important predisposing factor. The dopaminergic effects of carbamazepine may be responsible for the induction of tics.

Carbamazepine treatment of agitation associated with dementia.

Two patients with severe dementia and multiple medical problems but with no other psychiatric diagnoses were treated with carbamazepine for agitation. They tolerated the medication well and their behavior improved, consistent with carbamazepine's efficacy for agitation in other syndromes. Theoretical and practical implications are discussed.