Dental infections masquerading as skin lesions

Dental infection is a common cause of facial sinus; the external opening can masquerade as a variety of lesions. Surgical excision of the skin component alone fails to address the underlying problem and results in recurrence. Recognition and treatment of the underlying dental infection is required to allow the resolution of the associated skin lesion. Two illustrative cases are presented.

Regional cerebral volume measurements in late-life depression: relationship to clinical correlates, neuropsychological impairment and response to treatment

BACKGROUND

Elderly people who develop depression have demonstrable changes in cerebral structure but little is known of the relationship between regional cerebral volumes, treatment response and cognitive impairment.

METHOD

Forty-four patients with major depression diagnosed according to DSM-IIIR criteria underwent magnetic resonance imaging and regional cerebral volumes were quantified using multispectral analysis. Response to antidepressant treatment was assessed prospectively and a neuropsychological test battery was administered.

RESULTS

There was a trend for smaller fronto-temporal volumes in the treatment-resistant patients. Impaired immediate working memory was linked with reduced frontal and parietal lobe volume and impaired short-term memory functioning was associated with reduced temporal lobe volume. Ventricular enlargement was associated with prior administration of electro-convulsive therapy, poor physical health and later age at onset of first episode of depression.

CONCLUSION

In late-life depression, brain changes should not preclude vigorous antidepressant treatment. Regional cerebral volume changes may be a complication of poor physical health and are associated with memory dysfunction even upon recovery from depression.

Factors affecting survival of elderly nursing home residents

OBJECTIVE

To examine whether the admission characteristics of nursing home residents predict mortality and to look for factors that account for different mortality rates between those homes.

METHODS

A retrospective case note audit of the admission characteristics of residents in nursing homes registered with the Manchester Health Authority who died within a 12 month period and a group of current residents matched by age, sex and length of stay. Time between admission and death was examined using actuarial estimators of survival and factors predicting time between admission and death were examined using the proportional hazards model of Cox. Standardised mortality ratios (SMR) were calculated on each of the homes from the Office for National Statistics for Greater Manchester Metropolitan County. Logistic regression was used to assess those factors that predicted death at 1, 2 and 4 weeks and 3, 6 and twelve months after admission.

RESULTS

Following admission the mean survival time was 5.9 years. There was a wide variation in the mortality ratio between the homes and five of the 32 studied had SMRs of over 7. Increasing age, male sex, poor appetite, sleep disturbance, build, place of admission from, history of malignancy and respiratory disease and the number of prescribed drugs were all found to be significant predictors of mortality. Malignancy, pressure sores, poor appetite and number of prescribed drugs predicted death with 4 weeks after admission.

CONCLUSION

Some nursing homes have higher mortality rates than others although this was accounted for by the characteristics of the residents and not by any measurable characteristic of the nursing home environment.

Clinical features of dementia associated with apolipoprotein epsilon4: discrimination with a neural network genetic algorithm

BACKGROUND

It is unclear whether the APOE epsilon4 allele is associated with distinct clinical features in dementia.

METHOD

100 cases meeting ICD criteria for dementia were interviewed using standardized instruments and genotyped for APOE. The presence of the epsilon4 allele was used by a genetic algorithm neural network (GANN) to discriminate symptoms and signs.

RESULTS

The GANN selected six features: gender, systolic blood pressure, absence of ankle tendon reflexes, history of weight loss, history of falls, and interviewer observed lability of mood. Using these features, a neural network discriminated cases according to epsilon4 highly accurately (area under receiver operating characteristic=0.83, sensitivity=0.78, specificity=0.78).

CONCLUSIONS

A GANN is able to discriminate a clinically distinct group of features among dementia patients who express the epsilon4 allele.

Is the clinical expression of late-life depression influenced by brain changes? MRI subcortical neuroanatomical correlates of depressive symptoms

BACKGROUND

"Vascular depression" has recently been proposed. It is characterized by magnetic resonance imaging (MRI) T2-weighted subcortical lesions, a late onset of first episode of depression, and reduced heritability; a cerebrovascular etiology is suggested. The validity of "vascular depression" might be strengthened if an association was found between the subcortical lesions used to define it and particular depressive symptoms.

METHODS

A blinded cross-sectional examination of DSM-III-R depressive symptoms (American Psychiatric Association, 1987) and MRI T2-weighted subcortical lesions in 44 patients with late-life depression.

RESULTS

Many associations were found; however, because of multiple comparisons, their significance is viewed with caution. The most robust finding was that psychomotor retardation was independently related to total white-matter score. The odds of showing psychomotor retardation was increased 1.9 times for every point increase in severity of white-matter change.

CONCLUSION

In late-life depression the clinical expression of the depression is influenced by the pattern of MRI T2-weighted subcortical lesions. This gives some validity to the concept of an MRI-defined "vascular" subtype of late-life depression and strengthens the argument for including neuroimaging in the classification of late-life depression.

The prognostic significance of abnormalities seen on magnetic resonance imaging in late life depression: clinical outcome, mortality and progression to dementia at three years

OBJECTIVE

To study the course of depressive symptoms over 3 years, rate of dementia and mortality in relation to baseline neuroradiological abnormalities.

DESIGN

Retrospective casenote analysis of 38 patients (of 44) who had a Magnetic Resonance Imaging (MRI) scan 3 years earlier. Twenty-two patients also received a detailed interview.

RESULTS

Overall outcome was good for around two-thirds of the sample. Poorer clinical course was associated with lesions in pons and more than five Virchow Robins spaces in the corona radiata. Pontine raphe lesions and confluent periventricular lesions were associated with later dementia and with reduced survival from cardiovascular death. Males had more recurrences and a reduced survival.

CONCLUSIONS

MRI lesions influence outcome, mortality and the onset of dementia. However, because they are quite common in elderly depressed patients they have limited utility on their own as predictors of outcome. The association of periventricular lesions with dementia is a new finding, and suggests that the site and type of lesions may be as important than the quality of them.

What are the effects of nitrogen deficiency on growth components of lettuce?

Relationships between nitrogen (N) content and growth are routinely measured in plants. This study determined the effects of N on the separate morphological and physiological components of plant growth, to assess how N-limited growth is effected through these components. Lettuce (Lactuca sativa) plants were grown hydroponically under contrasting N-supply regimes, with the external N supply either maintained continuously throughout the period of study, or withdrawn for up to 14 d. Richards' growth functions, selected using an objective curve-fitting technique, accounted for 99.0 and 99.1% of the variation in plant dry weight for control and N-limited plants respectively. Sublinear relationships occurred between N and relative growth rates under restricted N-supply conditions, consistent with previous observations. There were effects of treatment on morphological and physiological components of growth. Leaf weight ratio increased over time in control plants and decreased in N- limited plants. Shoot:root ratio followed a similar pattern. On a whole-plant basis, assimilation of carbon decreased in N-limited plants, a response paralleled by differences in stomatal conductance between treatments. Changes in C assimilation, expressed as a function of stomatal conductance to water vapour, suggest that the effects of N limitation on growth did not result directly from a lack of photosynthetic enzymes. Relationships between plant N content and components of growth will depend on the availability of different N pools for remobilization and use within the plant.

Screening for cognitive impairment in older African-Caribbeans

BACKGROUND

There are increasing numbers of older African-Caribbeans in the United Kingdom. Screening instruments are commonly used in the detection of cognitive impairment, but have not been assessed within this population. This study aimed to develop culturally modified versions of screening instruments for cognitive impairment (Mini-Mental State Examination (MMSE) and Abbreviated Mental Test (AMT)) and to determine their sensitivity and specificity in the diagnosis of dementia.

METHODS

The instruments were modified using a process involving a community group of African-Caribbeans and an academic group of health professionals. They were used in a two-stage study involving community resident African-Caribbeans aged 60 years or over in inner-city Manchester, comparing the screening instruments against a computerized diagnostic interview.

RESULTS

One hundred and thirty people completed the study. The results for the largest subgroup, the Jamaicans (N = 96) were analysed. Effects of gender, age and education on the MMSE and AMT scores were evaluated. The correlations between the screening instruments and diagnostic interview were highly significant (P < 0.001). At appropriate cut-offs both screening instruments demonstrated high sensitivity and acceptable specificity levels.

CONCLUSIONS

A defined process with lay input has assisted in producing culturally modified versions of the MMSE and AMT that perform well compared with a diagnostic interview, if an appropriate cut-off is used. They are easy to administer and acceptable to older African-Caribbean people. The results need to be viewed within the limitations of the current study.

A new version of the geriatric depression scale for nursing and residential home populations: the geriatric depression scale (residential) (GDS-12R)

The objective was to develop a new short-form Geriatric Depression Scale (GDS-12R) suitable for older people living in nursing and residential care settings, including those persons with significant cognitive impairment. A total of 308 newly admitted residents of 30 nursing and residential homes in northwest England were interviewed using the Geriatric Depression Scale (GDS-15), the Mini-Mental State Examination, and the Affect Balance Scale (ABS). A 12-item version of the GDS was shown to have greater internal reliability than the 15-item version, because of the context-dependent nature of the deleted items. There was close agreement between the GDS-12R items and another indicator of depressed mood (a single item from the ABS). Furthermore, moderate to high levels of cognitive impairment did not affect the performance of the new version of the scale. The GDS-12R provides researchers and clinicians with a brief, easy-to-administer depression scale that is relevant to residential and nursing home populations.

Effects of a pharmacist's medication review in nursing homes. Randomised controlled trial

BACKGROUND

Older people in nursing and residential homes often have complex disabilities and behavioural disturbances. Recent publicity has highlighted the dangers of medication in this group, and controls over prescribing have been suggested.

AIMS

To investigate the effect of a review of medication by a pharmacist.

METHOD

An 8-month prospective trial of an active medication review by a pharmacist was carried out on 330 residents in nursing homes in Manchester.

RESULTS

The intervention group experienced greater deterioration in cognitive function and behavioural disturbance than the control group, but the changes in depression and quality of life were similar for both groups. The number of drugs prescribed fell in the intervention group, but not in the control group, with a corresponding saving in drug costs. The number of deaths was significantly smaller in the intervention homes during the intervention period (4 v. 14) but not overall during the study period as a whole (26 v. 28).

CONCLUSION

This clinical intervention reduced the number of medicines prescribed to elderly people in nursing homes, with minimal impact on their morbidity and mortality.

Effectiveness of cognitive-behavioural family intervention in reducing the burden of care in carers of patients with Alzheimer's disease

BACKGROUND

The majority of patients with Alzheimer's disease live outside institutions and there is considerable serious psychological morbidity among their carers.

AIMS

To evaluate whether family intervention reduces the subjective burden of care in carers of patients with Alzheimer's disease and produces clinical benefits in the patients.

METHOD

A prospective single-blind randomised controlled trial with three-month follow-up in which the experimental group received family intervention and was compared with two control groups.

RESULTS

There were significant reductions in distress and depression in the intervention group compared with control groups at post-treatment and follow-up. There were significant reductions in behavioural disturbance at post-treatment and an increase in activities at three months in patients in the intervention group. Based on an improvement on the General Health Questionnaire resulting in a carer converting from a case to a non-case, the number to treat was three immediately post-treatment and two at follow-up.

CONCLUSIONS

Family intervention can have significant benefits in carers of patients with Alzheimer's disease and has a positive impact on patient behaviour.

Dependency in older people recently admitted to care homes

OBJECTIVE

to investigate dependency and general health status of a cohort of older people admitted to residential or nursing homes for long-term care.

METHOD

we assessed 308 people aged over 65 years within 2 weeks of admission for long-term care to one of 30 nursing or residential homes in north-west England. Dependency was assessed using the Barthel activities of daily living index and the Crichton Royal Behaviour Rating Scale. We collected information from the homes' records on diagnosed conditions and current medication.

RESULTS

50% of the cohort were in a 'low dependency' band (Barthel score 13 - 20): 31% of those in nursing homes and 71% of those in residential homes. In nursing homes, low-dependency residents were more likely to be self-funding than those with higher dependency. Of a number of broad diagnostic groupings, only a diagnosis of dementia was associated with nursing- rather than residential-home admission. Of 47 residents who scored 9 or less on the Mini-Mental State Examination (indicating severe cognitive impairment), 85% had no diagnosis of dementia, neurological disorder or other psychiatric disorder.

DISCUSSION

the high proportion of new admissions of subjects with low dependency needs raises questions about the effective targeting of resources and about management of the boundary between home-based and institutional care. The existence of an important group of self-funded, low-dependency new admissions to nursing homes suggests a need to provide better assessment and placement services for those who are financially independent of local authorities. Many new admissions had conditions which might benefit from rehabilitation but there were almost no therapy staff in the studied homes. In some cases where severe cognitive impairment was evident, there was no evidence that the result of any formal pre-admission psychiatric evaluation had been communicated to nursing or care staff.

Recognition of depression by staff in nursing and residential homes

Newly admitted residents in long-term care facilities are particularly vulnerable to depression and the early recognition and treatment of depression is therefore crucial around the time of admission to a home. Staff from 30 nursing and residential homes were asked to assess newly admitted residents for depression using HoNOS 65+ and their responses were compared with residents' scores on the Geriatric Depression Scale (GDS-15). The findings indicated low levels of recognition by staff, with rates ranging from 15% to 27% of those identified as depressed, depending on the definition of depression used. There was no statistically significant difference in the rate of recognition between nursing staff and other care staff. A staff survey conducted in the 30 study homes indicated that fewer than 2% had received specific in-service training on depression in older people. The findings suggest that more needs to be done to raise staff awareness of depression in residents of nursing and residential homes, particularly in newly admitted residents.

Validating screening instruments for cognitive impairment in older South Asians in the United Kingdom

BACKGROUND

The numbers of older South Asians in the United Kingdom are rising. Investigation of their mental health has been neglected compared to their physical health.

OBJECTIVES

This study aimed to determine the sensitivity and specificity of modified versions of two screening instruments for cognitive impairment (Mini-Mental State Examination and Abbreviated Mental Test) in a community-based population.

DESIGN

Two-stage study comparing screening instruments against diagnostic interview.

SETTING

South, central and north Manchester.

SUBJECTS

Community-resident South Asians aged 60 years and over.

METHODS

Subjects were approached via their general practitioners and interviewed at home. Sensitivity and specificity for the screening instruments were calculated using receiver operating characteristic (ROC) curve analysis.

RESULTS

For the Gujarati population, the MMSE cutoff was >/=24 (sensitivity 100%, specificity 95%) and AMT>/=6 (sensitivity 100%, specificity 95%). For the Pakistani population, the MMSE cutoff was >/=27 (sensitivity 100%, specificity 77%) and AMT>/=7 (sensitivity 100%, specificity 87%).

CONCLUSIONS

Culturally modified versions of the Mini-Mental State Examination and Abbreviated Mental Test are acceptable and may have a high degree of sensitivity. They may assist with the recognition of cognitive impairment, if an appropriate cutoff is used.

Screening for depression in African-Caribbean elders

BACKGROUND

There are increasing numbers of older African-Caribbeans in the UK. Primary care staff often feel less confident about diagnosing depression in this group. Screening instruments may assist in making diagnoses in cross-cultural consultations.

OBJECTIVE

We aimed to determine the sensitivity and specificity of screening instruments for depression in older African-Caribbean people in Manchester, UK.

METHODS

We carried out a two-stage study to compare three screening instruments for depression (Geriatric Depression Scale, Brief Assessment Schedule Depression Cards, Caribbean Culture Specific Screen), with a computerized diagnostic interview for mental health disorders in older adults (Geriatric Mental State). The study was set in inner-city Manchester. The subjects were community-resident African-Caribbeans aged 60 years and over; 227 subjects were approached. Of the 160 people screened, 130 agreed to diagnostic interview. The main outcome measures were Spearman correlation coefficients; these were calculated between each screening instrument and the diagnostic interview. Receiver-operating characteristic (ROC) curve analysis was used to determine appropriate sensitivity and specificity for each instrument.

RESULTS

The results for the largest subgroup, the Jamaicans (n = 96/130), demonstrated highly significant correlations between screening instruments and diagnostic interview (P < 0.001). Each instrument had a high sensitivity: Brief Assessment Schedule depression cards (cut-off > or =6; sensitivity 90.9% (95% CI 58.8-99.8), specificity 82.1% (95% CI 74.0-90.3)), Caribbean Culture Specific Screen (cut-off > or =6; sensitivity 90.9% (95% CI 58.8-99.8), specificity 74.1% (95% CI 64.8-83.4)), and Geriatric Depression Scale (cut-off > or =4; sensitivity 100% (95% CI 97.1-100), specificity 69.1% (95% CI 59.6-79.2)).

CONCLUSIONS

These screening instruments demonstrate high sensitivity levels, if an appropriate cut-off point is used. The culture-specific instrument did not perform better than the traditional instruments. Health professionals should approach the consultation in a culturally sensitive manner and use the validated instrument they are most familiar with.

Personality change in dementia

This study examined the prevalence and nature of personality change in 99 patients with dementia of the Alzheimer type and multi-infarct dementia. Personality was assessed using an informant-rated inventory of the patient's personality before and after the onset of dementia, with the difference equating to a change in personality. Personality characteristics were related to the patients' age and sex, duration of illness, degree of cognitive impairment, the presence of a grasp reflex, and extrapyramidal signs. Personality change was found to be almost universal and negative in nature and was particularly associated with severity of cognitive impairment, longer duration of illness, and neurological signs. The findings reflect those from other studies and emphasize the biological basis of personality changes in dementia.

'Not knowing where I am doesn't mean I don't know what I like': cognitive impairment and quality of life responses in elderly people

OBJECTIVE

To elucidate the extent to which elderly people with cognitive impairment are able to answer questions about their quality of life.Design and setting308 elderly residents were interviewed within 2 weeks of admission to one of 30 residential or nursing homes in north-west England.

MEASURES

The Mini-Mental State Examination (MMSE), the Lancashire Quality of Life Profile (Residential) (LQOLP(R)), the Crichton Royal Behaviour Rating Scale (CRBRS) and the HONOS-65+.

RESULTS

Of the 308 subjects, LQOLP(R) interviews were attempted with 213 who scored 10 or over on the MMSE. Of the 213, 77.5% were found to be 'interviewable', ie able to answer the majority of questions in the LQOLP(R) and in doing so to give answers in which the interviewer had confidence. Of the seven cognitive domains measured by the MMSE, visual construction and registration were not significantly associated with interviewability. While orientation to time and recall were significantly associated with interviewability, many interviewable respondents had poor scores in these domains. No respondents were interviewable who scored less than 2 (out of 5) for orientation to place or less than 3 (out of 8) for language or less than 2 (out of 5) for attention.

CONCLUSIONS

A high proportion of elderly people can answer questions about their quality of life, even in the presence of significant cognitive deficits.