Educational interventions in delirium

In the absence of specific therapies, interventions for delirium are largely educational. This paper reviews educational interventions targeted at physicians, nurses, patients and their families. Most studies to date have had methodological deficiencies, and few have been developed in keeping with current principles for adult learning. Early studies focused on increased recognition of delirium, with less consistent measurement of patient centred outcomes. Subsequent studies provide limited evidence to suggest that, as a result of educational interventions, individual symptoms can be prevented, and, when delirium is present, its consequences - including death and prolonged hospital stays - can be diminished. Future studies should incorporate principles of adult learning and have improved methodological rigour. The strength of educational interventions needs to be assessed carefully. Interventions which are time-sensitive, less complex, directed to observable, patient-focused endpoints are more likely to be successful.

Spectrum of disease in vascular cognitive impairment

The recognition that cognitive impairment of vascular origin is not limited to multi-infarct dementia has led to the development of several sets of new criteria for vascular dementia (VaD). We set out to define the spectrum of disease in patients presenting with vascular cognitive impairment (VCI). Of 412 patients consecutively seen at a memory clinic, 80 had VCI. These patients had vascular cognitive impairment not dementia (n = 19), VaD (n = 48), and mixed Alzheimer's disease-VaD (n = 13). Radiographic patterns were: white matter changes only (40%); multiple infarcts (30%); single strategic stroke (14%), and no identified lesion (16%). Of note, 19 (24%) of these patients meet none of the currently published criteria for VaD. To better understand and treat ischaemic causes of cognitive impairment, the concept of VaD should be expanded to include patients who do not meet traditional dementia criteria.

Incidence and risk factors for delirium and other adverse outcomes in older adults after coronary artery bypass graft surgery

OBJECTIVE

To determine the incidence and risk factors for delirium after coronary artery bypass graft (CABG) surgery.

DESIGN

Prospective cohort.

SETTING

Cardiac surgery units of a tertiary care hospital.

PARTICIPANTS

Consecutive patients over age 65 years undergoing elective CABG surgery. Exclusion criteria included preoperative sensory or language barriers.

INTERVENTIONS

Each patient was assessed within 24 h before surgery for baseline demographic, medical and functional data. Incident delirium (within four postoperative days) was diagnosed by a study physician. Nine potential risk factors for delirium were subjected to univariate and multivariate analysis.

MAIN RESULTS

Of 75 consenting patients, three died during or soon after surgery and one was still comatose at follow-up. Of the remaining 71 participants, 23 (32%) experienced delirium. Those with delirium were more likely than those without delirium to have a history of a stroke (21% versus 4%, respectively, P=0.032) and to have had a longer duration of cardiopulmonary bypass (CPB) (113 mins versus 95 mins, respectively, P=0.025). A tendency to have experienced low cardiac output (83% versus 58%, respectively, P=0.061) postoperatively was also noted. Multivariate analysis confirmed past stroke and duration of cardiopulmonary bypass as risk factors.

CONCLUSIONS

Delirium in the elderly after CABG surgery is common. Its occurrence may be predisposed by a history of a stroke and precipitated by a longer duration of CPB.

Goal attainment scaling as a measure of clinically important change in nursing-home patients

OBJECTIVES

To assess the feasibility, validity and responsiveness of an individualized measure--goal attainment scaling-in long-term care.

DESIGN

Prospective descriptive study.

SETTING

One academic and three community-based long-term care facilities.

SUBJECTS

53 nursing-home patients seen in consultation between July 1996 and June 1997.

INTERVENTION

Specialized geriatric medicine consultation.

MAIN OUTCOME MEASURES

Effect size and relative efficiency of the Barthel index, hierarchical assessment of balance and mobility, global deterioration scale, axis 8 (behaviour) of the brief cognitive rating scale, cumulative illness rating scale and the goal attainment scale.

RESULTS

Mean goal attainment scale at follow-up was 46+/-7. The goal attainment scale was the most responsive measure, with an effect size of 1.29 and a relative efficiency of 53.7. The goal attainment scale did not correlate well with the other measures (-0.22 to 0.17).

CONCLUSION

Goal attainment scaling is a feasible and responsive measure in long-term care. Although fewer problems in nursing-home patients than elderly inpatients are susceptible to intervention, clinically important goals can be achieved in this population.

Validity and reliability of the Medical Outcomes Study Short Form-20 questionnaire as a measure of quality of life in elderly people living at home

BACKGROUND

the Medical Outcomes Study Short Form-20 (SF-20) questionnaire is recommended for health-related quality of life research, but there is little information on its utility in older people. We assessed the validity, reliability and feasibility of using the SF-20 in an elderly community-dwelling population.

METHODS

the SF-20 was administered to a stratified, random sample of 333 elderly subjects.

FINDINGS

assessment of content validity revealed that important domains were lacking, while others appeared to be inappropriately combined. Using Spearman correlation coefficients, the SF-20 had acceptable convergent and discriminant validity. A principal components analysis provided evidence for internal consistency for some of the subscales. Evidence for test-retest reliability was good.

INTERPRETATION

while the reliability and feasibility of the SF-20 appear satisfactory, concerns about validity and responsiveness should temper enthusiasm for its use with elderly people living at home.

The rate of decline in function in Alzheimer's disease and other dementias

BACKGROUND

Functional impairment over time is a necessary condition for the diagnosis of dementia. Increasingly, it is recognized that rates of decline may not follow a linear progression. This variability may indicate that dementia in Alzheimer's disease represents disease rather than inevitable aging. In order to investigate decline in function in dementia, we developed a model of the rate of decline in functions in Alzheimer's disease and in other dementias in comparison with normal aging.

METHODS

Secondary analysis of a cross-sectional, representative sample of Canadians aged 65 and older (N = 2,914) was performed. We calculated a measure identified as an impairment index, defined as the probability of the occurrences of an impairment or disability in a structured clinical examination.

RESULTS

The rate of functional decline varies for different diagnostic groups and increases with severity of the disease. The distribution for the rate of decline in dementia is distinct from that in aging without cognitive impairment. In those without cognitive impairment, the distribution is exponential. Elderly persons with dementia of any type showed a log-normal distribution.

CONCLUSIONS

The difference in the distributions between aging with and without dementia likely reflects fundamental differences in the processes of decline in functions in the two groups. This suggests that the declines seen in persons with dementia are distinct from normal aging. It also has implications for the testing of antidementia medications, in that modeling treatment effects based on an assumption of linear decline is likely to be flawed.

A standardized menu for Goal Attainment Scaling in the care of frail elders

Goal Attainment Scaling (GAS), an individualized measurement approach, is particularly attractive for the evaluation and care planning of frail elders, who often experience multiple, complex problems. Some service providers find GAS too unwieldy for routine use. A modified version of GAS that uses a standardized menu of goals and attainment levels has been developed by the Geriatric Assessment and Rehabilitation Unit of a regional referral hospital in Nova Scotia, Canada. This article reviews the development, implementation, benefits, and challenges of the standardized menu, as well as the results of a retrospective descriptive study of its measurement properties. The standardized menu appears to be a feasible, valid, and responsive alternative to traditional GAS, while retaining much of its individualized nature.

Aging-related clinical and health services research in Canada

Research by Canadian geriatricians has grown significantly since the Canadian Society of Geriatric Medicine was founded in 1981. Most research has been clinical or related to health service use. More recently, the Canadian Study of Health and Aging (CSHA) has proved an important focus for population-based research, and research on dementia. An increasing number of Canadian geriatricians have undertaken formal research training, and the CSHA study team and other groups are providing opportunities for multicentre, multidisciplinary, collaborative studies. These developments point to continued growth in research by Canadian geriatricians, most likely research with a clinical and population focus and employing multicenter designs.

Subcortical vascular dementia: survey of treatment patterns and research considerations

BACKGROUND

Since few studies have examined the effectiveness of therapies for subcortical vascular dementia, treatment guidelines are not available. Current patterns in the treatment of such dementias have not been studied.

OBJECTIVE

To determine the practice patterns of Canadian specialists for the treatment of subcortical vascular dementia, and to survey their opinions regarding issues which are important in the design of a randomized controlled trial (RCT) in this field.

DESIGN

National survey of all specialists certified in Neurology or Geriatric Medicine.

RESULTS

Of responding physicians (78%) prescribed antithrombotic therapy for patients with vascular dementia. Most begin treatment with aspirin 325 mg daily (64%). The next three most common initial treatments were; no pharmacotherapy (12%), aspirin 650 mg daily (11%), and aspirin 1300 mg daily (11%). If the dementia continued to progress despite initial therapy, the treatment options were more varied. Most specialists (69%) believed that an RCT to assess the efficacy of aspirin in vascular dementia is warranted. The majority (69%) also felt that serial neuroimaging would be required for participants in such a trial, with magnetic resonance imaging being cited most frequently (41%). The majority of specialists considered three years as the minimum duration for such a trial.

CONCLUSIONS

Specialist physician practice patterns vary significantly for the treatment of patients with subcortical vascular dementia. Most physicians believe that an RCT testing the efficacy of aspirin in this condition is required. However, before such a trial can be conducted, many methodological difficulties need to be addressed.

Testing the measurement properties of the Short Form-36 Health Survey in a frail elderly population

The Short Form-36 Health Survey (SF-36) is a widely used measure of health-related quality of life, however, its suitability for frail older persons is not well documented. This study examines the measurement properties of the SF-36 in a frail older patient population. Patients consecutively admitted to two geriatric services (n = 146) were administered the SF-36 and comparative measures on admission and discharge. Internal consistency (0.75-0.91) and test-retest reliability (0.24-0.80) did not meet standards for clinical application of the tool. Four subscales were moderately correlated with comparative measures (Physical Function 0.53 to -0.76; Bodily Pain -0.61; Vitality -0.58; Mental Health -0.63). The results of effect size, standardized response mean, and relative efficiency statistics were consistent in documenting only minimal change for the SF-36 subscales. The SF-36 appears to be reliable and valid, although its ability to monitor clinical change for frail older patients is questionable.

Outcomes of coronary artery bypass surgery in elderly people

OBJECTIVES

To document the impact of coronary artery bypass (CABG) surgery on quality of life in elderly people three months after surgery; to compare quality of life measures; to examine predictors of poor quality of life; and to assess the predictive validity of global clinical rating scales.

STUDY DESIGN

Prospective cohort study with postoperative, three-month and one-year follow-up.

SETTING

A 700-bed tertiary care teaching hospital in Halifax, Nova Scotia.

PATIENTS

One hundred of 200 consecutive patients, 75 years and older, undergoing CABG.

MEASURES

Demographic information, clinical data and global clinical ratings were collected at baseline to assess risk for adverse outcome (death, stroke, functional impairment) at each follow-up. Quality of life three months post-CABG was documented using the RAND 36-Item Health Survey and the Seattle Angina Questionnaire.

MAIN RESULTS

Perioperative deaths occurred in four patients, disabling strokes in six and postoperative complications in seven. Three additional deaths occurred by the three-month follow-up and nine more by one year. On average, important improvements in quality of life were observed at three months' follow-up, using both assessments of quality of life.

CONCLUSIONS

Many elderly patients do well after CABG surgery, but a higher proportion than is seen in younger patients have complications leading to death and disability. A global clinical measure by the attending cardiologist at baseline did not identify patients at a higher risk. Follow-up studies are needed to assess long term outcomes of older patients at higher risk of death or a poor quality of life after CABG surgery.

Donepezil for treatment of dementia with Lewy bodies: a case series of nine patients

Dementia with Lewy bodies (DLB) is common. Symptomatic treatment can be difficult. We reviewed nine consecutive patients with DLB (mean age 77.5 [range 67 to 84] years; seven men and two women; mean duration of disease 3.7 [range 1.5 to 8.0] years) who had been treated with donepezil. Each initially received 2.5 to 5 mg per day of donepezil, and was stabilized on 5 mg per day. Donepezil was increased to 10 mg per day in five patients. The mean observation period was 12 (range 8 to 24) weeks. Target symptoms included cognition, hallucinations, parkinsonism, and functional abilities. By both cognitive testing and family reports, cognition improved in seven of nine patients, remained the same in one of nine, and fluctuated in one of nine (mean Mini-Mental State Examination change 4.4 +/- 6.3 points). Function was improved or maintained in six of nine patients and fluctuated in two of nine. Hallucinations initially worsened, then fluctuated in one patient, but improvement in frequency, duration, and content was reported in eight of nine cases. In three of nine patients, treatment with donepezil resulted in worsening of parkinsonism, which in each case responded to levodopa/carbidopa. Treatment of DLB patients with donepezil for 12 weeks most commonly improved hallucinations, and sometimes improved cognition and overall function. Treatment with donepezil was sometimes associated with worse parkinsonism.

Prevalence of diabetes mellitus in elderly people in Canada: report from the Canadian Study of Health and Aging

AIMS

to estimate the age-specific prevalence of diabetes mellitus in elderly people in Canada, and to examine the effect of method of ascertainment on the estimation of prevalence.

METHOD

three measures of diabetes were used in a secondary analysis of the Canadian Study of Health and Aging--a 1991 nation-wide cross-sectional study of the prevalence of dementia in a sample of 10,263 elderly subjects (aged 65-106 years).

RESULTS

of community-dwelling subjects, 10.3% reported diabetes. Supplementing this information with clinical reports and random plasma glucose measurements increased the prevalence to 12.0% in the community, 17.5% in institutions and 12.4% overall.

CONCLUSION

diabetes is common in elderly people, although the prevalence falls in the very elderly. The method of ascertainment influences estimation of prevalence.

Multidimensionality in instrumental and basic activities of daily living

Although the use of self-reported ADL (activity of daily living) scales has a long history, the Katz-based assumptions of unidimensionality and hierarchy are increasingly found lacking, and ADLs alone are found to underestimate dysfunction and disability. Data from nearly 8900 elderly respondents in the community sample of the 1991 Canadian Study of Health and Aging were used to examine the measurement properties of a modified version of the Older Americans Research Survey (OARS) ADL and IADL items combined. A multidimensional factor structure was revealed, with three levels of functional ability possessing internal consistency. We conclude that assumptions regarding ADL/IADL unidimensionality and hierarchy are not always valid, and that ADL and IADL items should be considered in combination to capture a greater range of functional disability prevalence. We also suggest that expectations of precise measurement of functional dependence by (I)ADL scales should perhaps be relaxed to the goal of simply differentiating broad levels of self-reported functioning (such as basic, intermediate, and complex), within which some tasks are roughly equivalent. Because these scales are widely used as screening tools and in shaping policy, we suggest that employing a more empirically grounded measurement standard has the potential to reduce bias due to item complexity and task specificity, facilitate standardization, and more reliably predict outcomes.

Comprehensive geriatric assessment. Helping your elderly patients maintain functional well-being

In this article, three geriatricians describe an approach to comprehensive geriatric assessment that takes into account the multiple social and medical problems that affect the functional well-being of frail elderly patients. With a 45- to 90-minute time investment, physicians can obtain an inventory of the factors that threaten an elderly patient's independence and gain a fuller understanding of the patient's complex needs.

Retrospective diagnosis of dementia using an informant interview based on the Brief Cognitive Rating Scale

The accuracy of a dementia diagnosis by specialist physicians, as verified at an autopsy, is greater than 90% in many series. Donations of brains to the Maritime Brain Tissue Bank (MBTB) by individuals who did not have expert dementia diagnoses before death led us to investigate whether clinical features could also be detected retrospectively. Informants for 36 individuals whose brains were in the MBTB (18 women, mean age = 79 years; pathologic diagnoses: 75% Alzheimer's disease [AD]; 8.4% vascular or mixed dementia) were interviewed by specialist physicians using a semistructured retrospective interview based on the Brief Cognitive Rating Scale (BCRS) (range = 1 [no impairment] to 7 [terminal dementia]). The mean duration of dementia was 8.5 +/- 12.8 years based on proxy reports, and most cases suggested severe dementia--(stage 6 [severe] or 7 [terminal])--on the retrospective BCRS (RetroBCRS) before death. A score of 4 or more on the RetroBCRS had 100% sensitivity and specificity in detecting dementia. The RetroBCRS score correlated moderately with duration (.51). In linear and logistic regression models adjusted for age and sex, RetroBCRS staging helped explain 93% of the variation in duration. The accuracy of the retrospective diagnosis of the cause of dementia, compared with autopsy, was 92%. The RetroBCRS used by an expert physician with a reliable informant is a valid method of detecting dementia and determining whether AD was present.

Vector diagnostics in dementia derived from Bayes' theorem

This paper introduces the concept of vector diagnostics. In contrast to the conventional approach where one diagnosis takes precedence, the authors propose an alternative strategy that addresses the clinical reality of comorbidity and multiple diagnoses for an individual. Based on a Bayesian approach, the probability distribution for the etiologically heterogeneous dementia diagnoses is estimated from the Canadian Study of Health and Aging database. These data were collected between February 1991 and May 1992. This method facilitates the establishment of a probability for more than one diagnosis within a given individual. By analyzing the correspondence between diagnostic groups, it is demonstrated that some clinical diagnoses are not reliably distinguished on the basis of the considered subset of symptoms and signs. As a consequence, the conventional diagnostic categories might require revision. The resulting probabilistic algorithm allows for the mining of existing epidemiologic databases for patterns of signs and symptoms that characterize emerging diagnostic categories which might better account for the heterogeneity of the dementia subtypes and individual variability.

Medical management of frailty: confessions of a gnostic

Geriatric Medicine is concerned chiefly with the care of frail elderly people, especially when they become ill. Physicians face special challenges in dealing with such patients, who tend to have multiple interacting medical and social problems, impaired function, altered pharmacokinetics and pharmacodynamics, atypical disease presentations and to be affected by polypharmacy. The joy of geriatrics is in systematically meeting each of these challenges, but the techniques that geriatricians use to do so must not be kept secret. More must be done to encourage all physicians to use these techniques in caring for frail elderly people who are ill.

Lessons from mixed dementia

With reconsideration of the role of vascular risk factors for Alzheimer's disease (AD; Gorelick et al., 1996), and with a recent Consortium to Establish a Registry for Alzheimer's Disease (CERAD) report that pure vascular dementia may be more difficult to find than has been widely assumed (Hulette et al., 1997), it is appropriate to reevaluate our understanding of so-called mixed dementia, or the dementia syndrome that arises from the combination of AD and ischemic vascular injuries. Such a reevaluation leads to potentially important lessons, an outline of which is presented here.

Prevalence and severity of cognitive impairment with and without dementia in an elderly population

BACKGROUND

Not all cognitively impaired people have dementia, but those who do not meet current criteria for dementia have received little study. We report a comprehensive estimate of the prevalence of "cognitive impairment, no dementia" (CIND) in an elderly population.

METHODS

The Canadian Study of Health and Aging gathered population representation information about elderly Canadians aged 65 and over from 36 cities and surrounding areas in five regions. In each region, the sample size was 1800 people in the community and 250 people in institutions. Patients in the community were screened for cognitive impairment by means of the modified mini-mental state examination. Those who scored below the cut-off point (n = 1106) and a randomly selected sample of those who scored above the cut-off point (n = 494) were referred for clinical examination. 59 individuals unable to take the screening test were also assessed clinically. We selected 17 long-term care institutions in each region, and then randomly selected consenting residents of these institutions for clinical assessment (n = 1255).

RESULTS

The prevalence of CIND was 16.8%, which was more than all types of dementia combined (8.0%). The prevalence of all types of cognitive impairment, including dementias, increased with age. Patients with CIND were three times more likely to be living in institutions than were cognitively unimpaired patients (odds ratio 3-1 [95% CI 2.4-3.9]). Circumscribed memory loss has a prevalence of 5.3% in the elderly Canadian population, and was the most common category. CIND was related to some degree of functional impairment in elderly patients.

INTERPRETATION

CIND is commonly associated with functional disability and a need for institutional care. This diagnostic category includes a costly group of disorders that merit further study.

A randomized, controlled trial of linopirdine in the treatment of Alzheimer's disease

OBJECTIVES

We tested the efficacy and safety of linopirdine, a novel phenylindolinone, in the treatment of Alzheimer's disease.

METHODS

A multicentre, randomized, double-blind, parallel group, placebo-controlled trial of linopirdine (30 mg three times per day or placebo). Patients (n = 382, 55% male, 98% Caucasian, age range 51-95 years) with mild or moderate Alzheimer's disease, of whom 375 received at least one treatment dose were analysed. There were no important differences between the groups at baseline.

RESULTS

No difference was seen in Clinical Global Impression scores between patients receiving placebo and those receiving linopirdine (n = 189). Small differences in the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) scores were seen throughout the study favouring linopirdine; at 6 months the ADAS-Cog scores were 20.2 (linopirdine) and 22.1 (placebo) p = 0.01.

CONCLUSIONS

This trial did not detect clinically meaningful differences in patients receiving linopirdine for 6 months, despite evidence of a small degree of improved cognitive function. Further studies may benefit from more sensitive tests of treatment effects in Alzheimer's disease.