Environmental volunteering and health outcomes over a 20-year period

PURPOSE

This study tested the hypothesis that volunteering in environmental organizations in midlife is associated with greater physical activity and improved mental and physical health over a 20-year period.

DESIGN AND METHODS

The study used data from two waves (1974 and 1994) of the Alameda County Study, a longitudinal study of health and mortality that has followed a cohort of 6,928 adults since 1965. Using logistic and multiple regression models, we examined the prospective association between environmental and other volunteerism and three outcomes (physical activity, self-reported health, and depression), with 1974 volunteerism predicting 1994 outcomes, controlling for a number of relevant covariates.

RESULTS

Midlife environmental volunteering was significantly associated with physical activity, self-reported health, and depressive symptoms.

IMPLICATIONS

This population-based study offers the first epidemiological evidence for a significant positive relationship between environmental volunteering and health and well-being outcomes. Further research, including intervention studies, is needed to confirm and shed additional light on these initial findings.

Preparing to implement a self-management program for back pain in new york city senior centers: what do prospective consumers think?

OBJECTIVE

Prior to testing the feasibility/potential efficacy of a newly developed self-management pain program for seniors with back pain, this study sought to: 1) determine prospective consumers' prior exposure to self-management pain programs, 2) determine their willingness to participate in the new program, and 3) ascertain perceived barriers/facilitators to program participation.

DESIGN

Cross-sectional survey.

SETTING

Six senior centers located in New York City.

PARTICIPANTS

We enrolled a race/ethnicity stratified (African American, Hispanic, or non-Hispanic White) sample of 90 subjects who were ages 60 years or older and had chronic back pain.

RESULTS

While 60% of non-Hispanic Whites reported prior participation in a self-management pain program, fewer Hispanic (23%) and African Americans (20%) participants reported prior participation. Most participants (80%) were strongly willing to participate in the new program. Multivariate analyses revealed that only pain intensity had a trend toward significance (P = 0.07), with higher pain scores associated with greater willingness to participate. Few barriers to participation were identified, however, respondents felt that tailoring the course to best meet the needs of those with physical disabilities, providing flexibility in class timing, and informing individuals about program benefits prior to enrollment could help maximize program reach. No race/ethnicity differences were identified with respect to willingness to participate or program participation barriers.

CONCLUSIONS

These data support efforts to disseminate self-management pain programs in older populations, particularly minority communities. The recommendations made by participants can help to guide implementation efforts of the newly developed pain program and may help to enhance both their reach and success.

A Community-Based Participatory Critique of Social Isolation Intervention Research for Community-Dwelling Older Adults

This article examines the dialogue that occurred within the structure of a Research-to-Practice Consensus Workshop that critiqued academic research priorities regarding social isolation among community-dwelling older adults and identified practice-based suggestions for a social isolation research agenda. The investigators adapted the scientific consensus workshop model to include expert practitioners and researchers in a discussion of the current state and future directions of social isolation intervention research. The group's critique resulted in several key recommendations for future research including the need for a social isolation measure with specific capacity to identify isolated older adults during a community crisis. This study demonstrates that the Research-to-Practice Consensus Workshop model can be used successfully to identify priority areas for research that have implications for community practice, construct an evidence base more relevant for community application, strengthen existing community-researcher partnerships, and build agency and practitioner capacity to take part in community-based participatory research.

The association of sexual trauma with persistent pain in a sample of women veterans receiving primary care

BACKGROUND

Women veterans report high rates of persistent pain and high rates of sexual trauma. We sought to determine whether the presence and intensity of persistent pain, as well as level of pain-related interference, in the VA Connecticut Women's Clinic population was positively associated with reports of sexual trauma.

METHODS

Women presenting for routine appointments at the VA Connecticut Women's Health Center were recruited for study. Participants (N = 213) provided detailed information about their demographic, psychosocial, clinical, pain, and sexual trauma status. Bivariate and multivariate analyses were conducted to determine whether a report of sexual trauma was independently associated with the presence of pain, and levels of pain intensity and pain-related interference.

RESULTS

A substantial majority (78%) reported an ongoing pain problem, whereas the prevalence of any reported sexual trauma was 36%. In bivariate analysis, persistent pain was associated with a greater number of chronic conditions (P < 0.01), depression symptom severity (P < 0.05), a history of military sexual harassment (P < 0.05), and military forced sex (P < 0.05). In a multivariate logistic regression analysis, persistent pain was independently associated with having at least two (OR 3.32, 95% CI 1.11, 9.90), or three or more chronic conditions (OR 7.56, 95% CI 2.34, 24.4) and depressive symptom severity score (OR 1.10, 95% CI 1.02, 1.19), but was not associated with sexual trauma (OR 1.70, 95% CI 0.66, 4.42). In multivariate linear regression analyses that included only those who reported pain at the time of the assessment, white race (P < 0.05) and sexual trauma histories (P < 0.05) were significantly associated with level of pain intensity, whereas being married (P < 0.01) was negatively associated with pain intensity. Depressive symptom score (P < 0.001) and sexual trauma (P < 0.05) were also significantly associated with level of pain interference.

CONCLUSIONS

Reported sexual trauma is prevalent and while not independently associated with the presence of pain among women veterans in our study, for those who have pain, it is associated with greater pain intensity and pain-related interference.

Sex after seventy: a pilot study of sexual function in older persons

INTRODUCTION

Limited information is available regarding sexual functioning among adults aged 70 years and older.

AIMS

To assess sexual functioning among older men and women, and ascertain patient-physician communication patterns about sexual functioning.

METHODS

Prospective participants were approached prior to scheduled appointments with their primary care physician. In-depth sexual histories were obtained along with data on their demographic, medical, psychological, and cognitive status.

MAIN OUTCOME MEASURES

Sexual functioning was assessed using standardized questionnaires, and simple yes/no questions were administered to ascertain information regarding patient-physician communication practices about sex.

RESULTS

Of the 74 eligible patients approached, 50 (68%) participated. The participants had a mean age +/- standard deviation (SD) of 81 +/- 6 years and most (56%) were women. Eighteen percent of the women and 41% of the men were sexually active. The most commonly reported sexual activity was intercourse for men and masturbation for women. Among the women, the most commonly cited reason for being sexually inactive was "no desire," whereas for most men, it was "erectile dysfunction." Sexual function scores for women were low across each category (lubrication, desire, orgasm, arousal, pain, and satisfaction.) For men, low sexual function scores were found in the domains of erectile function, orgasm, and overall satisfaction, but not desire. Only 4% of the women (vs. 36% of men) reported initiating a discussion about sexual function with their physician in the past year, whereas 7% of the women (vs. 32% of men) reported that their physician inquired about the topic in the preceding year. Finally, 32% of the women (vs. 86% of men) felt that physicians should initiate discussions about sexual function.

CONCLUSION

In this study of older adults, a minority reported current sexual activity. Among sexually inactive women, most did not wish to resume activity, whereas desire for sexual activity remained high among men, despite substantial problems with erectile dysfunction.

Severe deficiencies of IGF-I, IGF-II, IGFBP-3, ALS and paradoxically high-normal bone mass in a child with insulin-resistance syndrome (Rabson-Mendenhall type)

Rabson-Mendenhall syndrome is a rare genetic disorder characterized by severe insulin resistance and hyperinsulinemia due to defects in signaling through the insulin receptor. Herein, we describe a new case of Rabson-Mendenhall syndrome in which investigations of the growth hormone (GH) - insulin-like growth factor (IGF) axis - reveal severe deficiencies in total and free insulin-like growth factor-I (IGF-I), IGF-II, IGF-binding protein-3 (IGFBP-3), and the acid labile subunit (ALS). Based on these findings, we anticipated significant bone deficits, as have been described in other clinical scenarios in which the IGF axis is significantly perturbed. Long-bone studies revealed no gross malformations. Paradoxically, DXA scanning revealed a total body bone density Z-score of +2.0 (0.8 gm/cm(2)), suggesting an overall high-normal BMD for age and a high BMD corrected for bone or height age. The mechanisms by which BMD is protected from severe deficiencies in the IGF-axis are unknown, yet may involve enhanced IGF sensitivity, increased local production of IGFs, and/or supra-physiological concentrations of insulin substituting for the actions of IGFs in bone.

Can hip protector use in the nursing home be predicted?

OBJECTIVES

To identify resident- and caregiver-related factors that influence hip protector (HP) usage.

DESIGN

Prospective observational cohort study over 6 weeks.

SETTING

A 409-bed nursing home located in New York City.

PARTICIPANTS

Fifty-two residents and 60 certified nursing assistants (CNAs).

INTERVENTION

Free HPs were provided to residents enrolled in the study.

MEASUREMENTS

HP adherence (number of hours HPs were worn/shift); HP users (subjects who used HPs for more than 1 hour during any 8-hour shift as recorded by CNAs in week 6 or who used HPs at checks performed by research staff in week 6 and intended future use); CNAs' scores on a questionnaire quantifying osteoporosis knowledge, opinions on HPs, job satisfaction, and health locus of control.

RESULTS

Sixty-eight percent of residents were HP users. Factors independently associated with this outcome included male sex, age, Parkinson's disease, family involvement, impaired cognition, dependent ambulation, and CNAs' sense that chance affects health outcomes. In multivariate models, anxiety, resistive behaviors, ambulation, and fall history in residents and CNAs' perceptions of HPs and their sense of how chance or other staff determine health outcomes predicted HP adherence.

CONCLUSION

Resident-related factors and CNAs' sense of external controls predicted HP users and HP adherence. CNAs' understanding of osteoporosis and HP affected only HP adherence. Most resident-related factors were not remediable but might help to target likely HP users. To improve HP adherence, educational programs should be designed to improve CNAs' understanding of osteoporosis and HP. Larger studies are needed to confirm these findings.

Completing an advance directive in the primary care setting: what do we need for success?

OBJECTIVES

To systematically review studies designed to increase advance directive completion in the primary care setting and employ meta-analytic techniques to quantify their effects.

DESIGN

Extensive bibliographic searches of English-language literature published from January 1991 through July 2005 were conducted. Investigators abstracted prespecified information (e.g., design, study duration, types of interventions employed) and advance directive completion rates for intervention and control arms in each investigation and calculated absolute rate differences (i.e., difference in completion rates between the two groups) for each study. Individual study and pooled-effect sizes were also calculated, along with 95% confidence intervals (CIs).

SETTING

Literature review.

RESULTS

Eighteen studies were retained in the final sample. Most studies employed multimodal interventions. The most common approach consisted of educational materials directed at patients (through mailing or at visit) coupled with a patient-healthcare provider interaction in a group or individual setting (n=7). Absolute differences in completion rates varied from a high of 44% (favors intervention) to a low of -2% (favors control). Effect sizes could be calculated for 15 of the 18 studies. The pooled effect size was 0.50 (95% CI=0.17-0.83), indicating a moderate overall effect in favor of the intervention.

CONCLUSION

The majority of studies demonstrated statistically significant effects associated with the advance directive intervention. The most successful interventions incorporated direct patient-healthcare professional interactions over multiple visits. Passive education of patients using written materials (without direct counseling) was a relatively ineffective method for increasing advance directive completion rates in the primary care setting.

Light to moderate alcohol consumption is associated with better cognitive function among older male veterans receiving primary care

Among older persons, the effects of light to moderate alcohol consumption on cognitive function remain inadequately defined. The authors sought to determine whether light to moderate drinking is associated with better cognitive function among older men. Participants included men aged 65 years or older enrolled in a Veteran's Administration (VA) primary care clinic. Current (past 1 year) and lifetime use, cognitive functioning (as determined by the Trail Making Part B, Symbol Digit, FAS, and Hopkins Verbal Learning tests), and demographic, psychosocial, and medical status were obtained using standardized methods. Participants (N = 760) had a mean age of 74 (range, 65-89) years. Current drinkers (n = 509) as compared with never (n = 31) and former (n = 220) drinkers demonstrated significantly better cognitive performance on 3 (Trails B, Symbol Digit, and Hopkins Verbal Learning) of the 4 tests (P < .01 for all comparisons). In multiple linear regression models, current light to moderate drinking (ie, 7 or fewer drinks per week), as compared to a reference group of never and former drinkers, was associated with better performance on the Trails B, Symbol Digit, and Hopkins Verbal Learning tests (P < .01 for all comparisons). The number of years drinking 7 or fewer drinks per week also was independently associated with better cognitive performance. Current consumption of 7 or fewer drinks per week and the number of years drinking at this level are both associated with better cognitive performance in older male veterans receiving primary care. These findings are consistent with the hypothesis that light to moderate drinking confers cognitive benefits to older persons.

Are Commonly Ordered Lab Tests Useful Screens for Alcohol Disorders in Older Male Veterans Receiving Primary Care?

Although mean corpuscular volume (MCV), aspartate aminotransferase (AST), alanine aminotransferases (ALT), and the AST/ALT ratio are sometimes used as markers of alcohol disorders, their utility has not been established in older persons. We determined the tests' performance characteristics for (1) at-risk drinking, (2) CAGE positivity, (3) at-risk drinking and CAGE positivity, and (4) a clinician-recorded diagnosis of alcohol abuse/dependence in a study of older male veterans receiving primary care. Participants (n = 587) included patients who had MCV, AST, and/or ALT data collected as part of routine care no more than 12 weeks before or after enrollment. MCV, AST, and ALT test results were obtained from the VA's database. At enrollment, the Timeline Followback and Alcohol Use Disorders Identification Test (AUDIT) were used to identify at-risk drinkers (> or = 15 drinks per week or AUDIT score > or = 8), and the CAGE questionnaire was administered to identify participants with a history abuse/dependent drinking (CAGE score > or = 2). Participants' medical records were reviewed to identify subjects with a clinician-recorded diagnosis of alcohol abuse/dependence. The prevalence of abnormal test results for MCV (threshold value = > 98), AST (> 41), ALT (> 41), and the AST/ALT ratio (> 2) was 11%, 4%, 4%, and 5%, respectively. The occurrence of at-risk drinking, CAGE positivity, at-risk drinking and CAGE positivity, and a clinician-recorded diagnosis of alcohol abuse/dependence was 11%, 25%, 5%, and 9%, respectively. Test sensitivity ranged from 3.9% to 25.4% and specificity from 88.5% to 97.1%, whereas positive likelihood ratios varied from 0.72 to 4.01 and negative likelihood ratios from 0.82 to 1.04. Areas under the receiver operating characteristic curve were similar (range = 0.50-0.58) across tests. In conclusion, MCV, AST, ALT, and the AST/ALT ratio are not useful markers of alcohol disorders in older male veterans.

Properties and substrate of slow pathway exposed with a compact node targeted fast pathway ablation in rabbit atrioventricular node

INTRODUCTION

The properties and substrates of slow and fast AV nodal pathway remain unclear. This applies particularly to the slow pathway (SP), which is largely concealed by fast pathway (FP) conduction. We designed a new FP ablation approach that exposes the SP over the entire cycle length range and allows for its independent characterization and ablation.

METHODS AND RESULTS

Premature stimulation was performed before and after FP ablation with 5.4 +/- 1.9 lesions (300-microm diameter each; overall lesion size 1.4 +/- 0.5 mm) targeting the junction between perinodal and compact node tissues in seven rabbit heart preparations. The resulting SP recovery curve and control curve had the same maximum nodal conduction time (165 +/- 22 msec vs 164 +/- 24 msec; P = NS) and effective refractory period (101 +/- 10 msec vs 100 +/- 9 msec; P = NS). The two curves covered the same cycle length range. However, the SP curve was shifted up with respect to control one at intermediate and long cycle lengths and thus showed a longer minimum nodal conduction time (81 +/- 15 msec vs 66 +/- 10 msec; P < 0.01) and functional refractory period (180 +/- 11 msec vs 170 +/- 12 msec; P < 0.05). The SP curve was continuous and closely fitted by a single exponential function. Small local lesions (2 +/- 1) applied to the posterior nodal extension resulted in third-degree nodal block in all preparations.

CONCLUSION

The posterior nodal extension can sustain effective atrial-His conduction at all cycle lengths and account for both the manifest and concealed portion of SP. Slow and FP conduction primarily arise from the posterior extension and compact node, respectively.

Exercise tolerance and quality of life in elderly patients with chronic atrial fibrillation

BACKGROUND

Atrial fibrillation is the most common arrhythmia affecting the elderly. Although the risk of cardioembolic stroke is well defined, the effects of chronic atrial fibrillation on exercise tolerance and quality of life have been less well quantified.

METHODS

We compared a group of 52 elderly patients with chronic atrial fibrillation to a group of 48 control patients in sinus rhythm. Each patient underwent an interview that incorporated the Short Form-36 Health Survey (SF-36) to quantify individual perceptions on quality of life. In addition each person underwent physiologic testing that included a Modified Bruce Protocol exercise tolerance test, 24-hour ambulatory monitor test, and an echocardiogram.

RESULTS

Both groups were elderly, 77 vs 76 years of age (P=0.35). The two groups had similar ejection fractions, 55.4% vs 58.4% (P=0.10). The atrial fibrillation patients demonstrated a higher level of comorbidity based on the Charlson Comorbidity Index, 2.46 vs 1.57 (P=0.03). On formal exercise testing there was no statistical difference in exercise duration between the two groups 9.0 vs 10.1 minutes (P=0.24). Similarly the Physical Summary Score (PCS) and the Mental Summary Score (MCS) of the SF-36 quality of life survey did not demonstrate a statistical difference between the two groups. PCS: 43.0 vs 45.9 (P=0.24);

MCS

52.5 vs 55.7 (P=0.07).

CONCLUSIONS

Despite a higher level of comorbidity, elderly, ambulatory patients with chronic atrial fibrillation demonstrate similar exercise tolerance and report similar quality of life to a group of age-matched control patients in sinus rhythm. There is a cohort of patients in chronic atrial fibrillation in whom a strategy of rate control and anticoagulation may be appropriate.

Similarities in the disturbances in cortical information processing in alcoholism and aging: a pilot evoked potential study

OBJECTIVE

To examine the hypothesis that chronic alcohol use causes accelerated aging of the brain.

METHODS

The auditory evoked potentials (EPs) were compared in three groups of 10 subjects each: (a) middle-aged individuals meeting DSM-IV criteria for alcohol dependence, (b) age- and gender-matched group of healthy individuals, and (c) an older (>65 years) group of gender-matched healthy individuals. Multiple levels of cortical information processing were examined using EPs. Early stages of information processing, related to sensory gating and stimulus classification (P50, N100/P200), were studied using a paired-click paradigm. Later stages of information processing associated with memory upgrading and identification of novel stimuli (P300) were studied using an oddball paradigm.

RESULTS

The amplitude and latency of the P300 of the alcoholic patients and the older healthy subjects differed significantly from those of the younger healthy group. Both groups showed changes that have been reported in association with aging. A tendency towards decreased sensory gating in later stages of information processing was noted in the aged healthy individuals.

CONCLUSIONS

These data suggest that alcohol dependence may accelerate the aging process. The tendency towards a sensory gating deficit during the attentive phase of information processing in older healthy subjects requires further investigation because it may be a marker for an increased proneness to developing psychotic symptoms in that group.

Outpatient management of patients with alcohol problems

This paper addresses the clinical presentation of patients with alcohol problems including screening, diagnosis, detoxification, treatment, referral, and longitudinal follow-up. The case-based discussion focuses on the clinical management of a patient whose hazardous drinking progresses to alcohol dependence and requires coordinated care. Ways in which internists can aid patients with alcohol problems by screening, giving brief advice, and providing appropriate referrals when indicated are discussed.

Screening for alcohol problems in primary care: a systematic review

BACKGROUND

Primary care physicians can play a unique role in recognizing and treating patients with alcohol problems.

OBJECTIVE

To evaluate the accuracy of screening methods for alcohol problems in primary care.

METHODS

We performed a search of MEDLINE for years 1966 through 1998. We included studies that were in English, were performed in primary care, and reported the performance characteristics of screening methods for alcohol problems against a criterion standard. Two reviewers appraised all articles for methodological content and results.

RESULTS

Thirty-eight studies were identified. Eleven screened for at-risk, hazardous, or harmful drinking; 27 screened for alcohol abuse and dependence. A variety of screening methods were evaluated. The Alcohol Use Disorders Identification Test (AUDIT) was most effective in identifying subjects with at-risk, hazardous, or harmful drinking (sensitivity, 51%-97%; specificity, 78%-96%), while the CAGE questions proved superior for detecting alcohol abuse and dependence (sensitivity, 43%-94%; specificity, 70%-97%). These 2 formal screening instruments consistently performed better than other methods, including quantity-frequency questions. The studies inconsistently adhered to methodological standards for diagnostic test research: 3 (8%) provided a full description of patient spectrum (demographics and comorbidity), 30 (79%) avoided workup bias, 12 (of 34 studies [35%]) avoided review bias, and 21 (55%) performed an analysis in pertinent clinical subgroups.

CONCLUSIONS

Despite methodological limitations, the literature supports the use of formal screening instruments over other clinical measures to increase the recognition of alcohol problems in primary care. Future research in this field will benefit from increased adherence to methodological standards for diagnostic tests.

New therapies for alcohol problems: application to primary care

Primary care physicians are frequently involved in the longitudinal care of patients with alcohol problems and in helping patients to decrease their alcohol consumption. Recent clinical trials provide evidence in support of new treatment strategies for these patients. Brief interventions have been used successfully to reduce alcohol consumption in patients with hazardous and harmful drinking. Twelve-step facilitation, cognitive behavioral, and motivational enhancement therapies have produced sustained drinking reductions in patients with alcohol dependence. Pharmacologic therapies, such as naltrexone and acamprosate, have been effective in decreasing alcohol consumption when provided along with psychosocial counseling in patients with alcohol dependence. The current review highlights the application of these new therapies to primary care physicians' efforts on behalf of their patients with alcohol problems.

Alcohol exposure and health services utilization in older veterans

The objective of this study was to determine if increased alcohol exposure is associated with greater use of health services among older veterans. A total of 129 older veterans (> or =65 years old), receiving longitudinal care in a Veterans' Administration primary care clinic, were followed retrospectively for up to 42 months. Subjects were screened at baseline for problem drinking with the CAGE or the quantity-frequency questions from the Alcohol Use Disorders Identification Test (QF-AUDIT), and stratified by exposure into three categories: abstainers, social drinkers, and problem drinkers. Outcomes included total outpatient clinic visits, laboratory tests, radiologic and other technologic procedures, as well as acute care hospitalizations. For all subjects (N = 129), no association was found between alcohol exposure and use of any outpatient services. Among CAGE-screened (n = 62) abstainers, social drinkers, and problem drinkers, significant differences were found in the median number of laboratory tests (7.3 vs. 3.4 vs. 7.1, P = 0.004) and hospitalizations (0.3 vs. 0.0 vs. 0.3, P = 0.001) per patient year of follow-up. No exposure-outcome associations were present, however, among QF-AUDIT-screened subjects (n = 67). We were unable to demonstrate a consistent relationship between alcohol exposure and health services utilization. The effects of alcohol on older veterans' use of health services varied with the method used to measure alcohol exposure. Additional studies are needed to determine whether multiple, or possibly new, measures can more precisely define the health effects of alcohol in older populations.

Hazardous and harmful alcohol consumption in primary care

Increasing emphasis has been placed on the detection and treatment of hazardous and harmful drinking disorders, particularly among patients who are seen in primary care settings. In this review, we summarize the epidemiology and health-related effects of hazardous and harmful drinking and discuss current methods for their detection and treatment. Hazardous drinking is defined as a quantity or pattern of alcohol consumption that places patients at risk for adverse health events, while harmful drinking is defined as alcohol consumption that results in adverse events (e.g., physical or psychological harm). Prevalence estimates range from 4% to 29% for hazardous drinking and from less than 1% to 10% for harmful drinking. Data from several recent large prospective studies suggest that alcohol consumption in quantities consistent with hazardous or harmful drinking may increase risk for adverse health events, such as hemorrhagic stroke and breast cancer. Existing screening instruments, such as the Michigan Alcoholism Screening Test (MAST) or the CAGE questionnaire, while excellent for detecting alcohol abuse or dependence, should not be used alone to screen for hazardous and harmful drinking. The Alcohol Use Disorders Identification Test (AUDIT) is currently the only instrument specifically designed to identify hazardous and harmful drinking. Treatment of these disorders in the form of brief interventions can be successfully accomplished in primary care settings, as demonstrated by a number of well-conducted randomized trials. Given its proven efficacy in the primary care setting, we recommend routine application of this treatment approach.

Alcohol use and functional disability among cognitively impaired adults

BACKGROUND

The extent to which alcohol exposure increases risk for functional disability among older adults with cognitive impairment has not previously been assessed.

OBJECTIVE

To examine the potential relationship between alcohol use and functional disability among older cognitively impaired adults.

DESIGN

Retrospective medical record review.

SETTING

Hospital-based geriatric assessment center.

PARTICIPANTS

Two hundred forty-two consecutive participants with Mini-Mental Status Examination scores of < or = 24.

MEASUREMENTS

Proxy-reported alcohol intake was classified in categories of never, former, light (< 1 drink/week), moderate (> or = 1 but < 14 drinks/week), and heavy (> or = 14 drinks/week) drinkers, and functional status was determined by proxy-reported performance in seven basic (BADL) and seven instrumental (IADL) activities of daily living (0 = poorest function and 14 = best function).

RESULTS

Compared with never drinkers, moderate drinkers demonstrated higher mean BADL (12.2 vs 11.4, P = .033) and IADL scores (6.6 vs 5.6, P = .067), whereas heavy drinkers had higher BADL (12.8 vs 11.4, P = .019) but lower IADL scores (4.8 vs 5.6, P = .425). Former drinkers demonstrated both lower BADL (10.8 vs 11.4, P = .107) and IADL scores (3.9 vs 5.6, P = .011) compared with never drinkers. Evaluation of a potential dose-response effect was limited due to low numbers of light and heavy drinkers.

CONCLUSIONS

Among cognitively impaired adults, moderate and heavy drinkers demonstrated better BADL function, whereas former drinkers had poorer IADL function, compared with never drinkers. Prospective studies that incorporate additional measures of exposure (e.g., cumulative lifetime consumption) and function (e.g., performance-based tests) may provide a more comprehensive understanding of alcohol's effects among older cognitively impaired adults.

Physician awareness of alcohol use disorders among older patients

OBJECTIVES

To determine primary care physicians' awareness of, and screening practices for, alcohol use disorders (AUDs) among older patients.

DESIGN

Cross-sectional telephone survey of a national sample of primary care physicians.

PARTICIPANTS

Physicians randomly sampled from the Masterfile database of the American Medical Association and stratified by specialty as family practice physicians, internal medicine physicians, and either family practice or internal medicine physicians with geriatric certification.

MAIN RESULTS

A total of 171 physicians were contacted: 155 (91%) agreed to participate, and responses were analyzed from 150 (50 family practice, 50 internal medicine, 50 with geriatric certification). The median prevalence estimate of AUDs among older patients was 5% for each group of physicians. In contrast to published prevalence rates of AUDs ranging from 5% to 23%, 38% of physicians reported prevalence estimates of less than 5%, and 5% cited estimates of at least 25%. Compared with the other groups, the physicians with geriatric certification were more likely to report no regular screening (42% vs 20% for family practice vs 18% for internal medicine, p = .01), while younger (<40 years) and middle-aged physicians (40-55 years) reported higher annual screening rates relative to older physicians (>55 years) (77% vs 60% vs 44% respectively, p = .03). Among physicians who regularly screened (n = 110), 100% asked quantity-frequency questions, 39% also used the CAGE questions, and 15% also cited use of biochemical markers.

CONCLUSIONS

Primary care physicians may "underdetect" AUDs among older patients. The development of age-specific screening methods and physician education may facilitate detection of older patients with (or at risk for) these disorders.

Academic calculations versus clinical judgments: practicing physicians' use of quantitative measures of test accuracy

PURPOSE

To determine how often practicing physicians use the customarily recommended quantitative methods that include sensitivity, specificity, and likelihood ratio indexes; receiver operator characteristic (ROC) curves; and Bayesian diagnostic calculations.

PARTICIPANTS AND METHODS

A random sample of 300 practicing physicians (stratified by specialty to include family physicians, general internists, general surgeons, pediatricians, obstetrician/gynecologists, and internal medicine subspecialists) were briefly interviewed in a telephone survey. They were asked about the frequency with which they used the formal methods, the reasons for non-use, and if they employed alternative strategies when appraising tests' diagnostic accuracy.

RESULTS

Of the 300 surveyed physicians, 8 (3%) used the recommended formal Bayesian calculations, 3 used ROC curves, and 2 used likelihood ratios. The main reasons cited for non-use included impracticality of the Bayesian method (74%), and nonfamiliarity with ROC curves and likelihood ratios (97%). Of the 174 physicians who said they used sensitivity and specificity indexes, 165 (95%) did not do so in the recommended formal manner. Instead, the physicians directly estimated tests' diagnostic accuracy by determining how often the test results were correct in groups of patients later found to have, or to be free of, the selected disease.

CONCLUSIONS

The results indicate that most practicing physicians do not use the formal recommended quantitative methods to appraise tests' diagnostic accuracy, and instead report using an alternative direct approach. Although additional training might make physicians use the formal methods more often, the physicians' direct method merits further evaluation as a potentially pragmatic tool for the determination of tests' diagnostic accuracy in clinical practice.

The consequences of overdiagnosis and overtreatment of Lyme disease: an observational study

BACKGROUND

The adverse consequences associated with overdiagnosis and overtreatment of Lyme disease, although previously recognized, have received inadequate attention.

OBJECTIVE

To determine the use of health services and occurrence of treatment-related illness, disability, and distress among patients in whom Lyme disease is inappropriately diagnosed or treated.

DESIGN

Observational cohort study.

SETTING

University-based Lyme disease clinic.

PARTICIPANTS

209 patients with a presumptive diagnosis of Lyme disease previously assigned by referring physicians, the patients themselves, or both.

MEASUREMENTS

Self-reported data, review of medical records, and standardized instruments were used to determine 1) use of health services in terms of number of outpatient visits, number of physicians seen, types of serologic tests, and days of antibiotic treatment; 2) occurrence of antibiotic-related adverse events; and 3) levels of disability, depression, and stress.

RESULTS

Of the 209 patients, 44 (21%) met criteria for active Lyme disease, 40 (19%) had previous but not active Lyme disease, and 125 (60%) had no evidence of current or previous infection. In general, patients with active Lyme disease (who were not the focus of this study) had good outcomes. Patients with previous Lyme disease and patients with no evidence of Lyme disease used considerable health resources (median number of office visits, 11 and 7; median number of serologic tests, 4 and 4; and median days of antibiotic treatment, 75 and 42), had frequent minor adverse drug events (53% and 55%), reported significant disability (proportion of symptomatic days during which normal activities could not be performed, 16% and 18%), and had high rates of depression (38% and 42%) and stress (52% and 45%).

CONCLUSIONS

Overdiagnosis and overtreatment of Lyme disease are associated with inappropriate use of health services, avoidable treatment-related illness, and substantial disability and distress.