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Wilkins JM. An amazing grace. J Am Geriatr Soc 2024; 72:280-281. [PMID: 37515517 DOI: 10.1111/jgs.18534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/06/2023] [Accepted: 07/09/2023] [Indexed: 07/31/2023]
Affiliation(s)
- James M Wilkins
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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Wilkins JM. Who's to Say? Self Versus Proxy Assessments for Persons With Dementia. Am J Geriatr Psychiatry 2024; 32:68-70. [PMID: 37783589 DOI: 10.1016/j.jagp.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 10/04/2023]
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Wilkins JM, Locascio JJ, Gomez-Isla T, Hyman BT, Blacker D, Forester BP, Okereke OI. Potential impact of the COVID-19 pandemic on everyday preferences for persons with cognitive impairment. Int Psychogeriatr 2023:1-6. [PMID: 37622323 PMCID: PMC10894308 DOI: 10.1017/s1041610223000650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
The COVID-19 pandemic and subsequent social distancing guidelines and restrictions brought on changes in the everyday experiences of older adults. It is not clear, however, to what extent the pandemic has impacted the importance of everyday preferences for persons with cognitive impairment (CI) or the proxy ratings of those preferences. The sample of this study included 27 dyads of persons with CI and their care partners. The Preferences for Everyday Living Inventory was used to assess importance of preferences among persons with CI; care partners completed concurrent proxy assessments. Mixed random and fixed effects longitudinal models were used to evaluate changes in ratings and concordance levels between persons with CI and care partners prior to and during the COVID-19 pandemic. Persons with CI rated autonomous choice preferences as significantly more important during the COVID-19 pandemic than before; there was no association between the COVID-19 pandemic and change in other everyday preferences domains or discrepancy in proxy assessments of everyday preferences. Identifying avenues to support and provide for autonomy in the decision-making of older adults with CI may offer a way forward in mitigating the psychological and behavioral impacts of the COVID-19 pandemic in this population.
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Affiliation(s)
- James M. Wilkins
- McLean Hospital, Belmont, MA; Harvard Medical School, Boston, MA
| | - Joseph J. Locascio
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
- Harvard Catalyst Biostatistical Consulting, Harvard Catalyst/CTSA; Harvard Medical School, Boston, MA
| | - Teresa Gomez-Isla
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Bradley T. Hyman
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Deborah Blacker
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | | | - Olivia I. Okereke
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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Wilkins JM, Locascio JJ, Gomez-Isla T, Hyman BT, Blacker D, Forester BP, Okereke OI. Projection of Care Partners' Preferences in the Proxy Assessments of Everyday Preferences for Persons With Cognitive Impairment. Am J Geriatr Psychiatry 2023; 31:254-263. [PMID: 36609056 PMCID: PMC10023418 DOI: 10.1016/j.jagp.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 12/01/2022] [Accepted: 12/03/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Bias in surrogate decision-making can occur when proxy decision-makers overestimate the degree to which their preferences are shared by others, resulting in a projection of their beliefs onto others. The purpose of this study is to assess projection of care partners' preferences onto surrogate assessments of everyday preferences for persons with cognitive impairment (CI) and to address clinical and demographic factors as predictors of projection. METHODS The sample included 116 dyads of persons with CI (Clinical Dementia Rating Scale score ≥ 0.5) and their care partners. The Preferences for Everyday Living Inventory (PELI) was used to assess importance of preferences among persons with CI. Care partners completed two separate PELI assessments: one from the perspective of the persons with CI (i.e., acting as a surrogate decision-maker) and one from their own perspective. To assess for projection of care partners' preferences onto surrogate assessments of preferences for persons with CI, two-step regression with multivariable-adjusted general linear models was used. RESULTS Significant projection was noted within the PELI domains of autonomous choice, personal growth, and keeping a routine (p < 0.005). More significant cognitive impairment was associated with increased projection within the PELI domains of autonomous choice and personal growth (p < 0.05). CONCLUSION The results of this study suggest that projection of care partners' own preferences may be a significant source of bias in proxy decision-making regarding everyday preferences for persons with CI, particularly for those with more significant CI.
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Affiliation(s)
- James M Wilkins
- McLean Hospital (JMW, BPF), Belmont, MA; Harvard Medical School (JMW, JJL, TGI, BTH, DB, BPF, OIO), Boston, MA.
| | - Joseph J Locascio
- Harvard Medical School (JMW, JJL, TGI, BTH, DB, BPF, OIO), Boston, MA; Department of Neurology (JJL, TGI, BTH, DB, OIO), Massachusetts Alzheimer's Disease Research Center, Massachusetts General Hospital, Boston, MA; Harvard Catalyst Biostatistical Consulting (JJL), Harvard Catalyst/CTSA, Boston, MA
| | - Teresa Gomez-Isla
- Harvard Medical School (JMW, JJL, TGI, BTH, DB, BPF, OIO), Boston, MA; Department of Neurology (JJL, TGI, BTH, DB, OIO), Massachusetts Alzheimer's Disease Research Center, Massachusetts General Hospital, Boston, MA
| | - Bradley T Hyman
- Harvard Medical School (JMW, JJL, TGI, BTH, DB, BPF, OIO), Boston, MA; Department of Neurology (JJL, TGI, BTH, DB, OIO), Massachusetts Alzheimer's Disease Research Center, Massachusetts General Hospital, Boston, MA
| | - Deborah Blacker
- Harvard Medical School (JMW, JJL, TGI, BTH, DB, BPF, OIO), Boston, MA; Department of Neurology (JJL, TGI, BTH, DB, OIO), Massachusetts Alzheimer's Disease Research Center, Massachusetts General Hospital, Boston, MA; Department of Psychiatry (DB, OIO), Massachusetts General Hospital, Boston, MA
| | - Brent P Forester
- McLean Hospital (JMW, BPF), Belmont, MA; Harvard Medical School (JMW, JJL, TGI, BTH, DB, BPF, OIO), Boston, MA
| | - Olivia I Okereke
- Harvard Medical School (JMW, JJL, TGI, BTH, DB, BPF, OIO), Boston, MA; Department of Neurology (JJL, TGI, BTH, DB, OIO), Massachusetts Alzheimer's Disease Research Center, Massachusetts General Hospital, Boston, MA; Department of Psychiatry (DB, OIO), Massachusetts General Hospital, Boston, MA
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Zhang Y, Wilkins JM, Bessette LG, York C, Wong V, Lin KJ. Antipsychotic Medication Use Among Older Adults Following Infection-Related Hospitalization. JAMA Netw Open 2023; 6:e230063. [PMID: 36800180 PMCID: PMC9938426 DOI: 10.1001/jamanetworkopen.2023.0063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/03/2023] [Indexed: 02/18/2023] Open
Abstract
Importance There are limited data on discontinuation rates of antipsychotic medications (APMs) used to treat delirium due to acute hospitalization in the routine care of older adults. Objective To investigate discontinuation rates and patient characteristics of APMs used to treat delirium following infection-related hospitalization among older US adults. Design, Setting, and Participants This retrospective cohort study was conducted using US claims data (Optum's deidentified Clinformatics Data Mart database) for January 1, 2004, to May 31, 2022. Patients were aged 65 years or older without prior psychiatric disorders and had newly initiated an APM prescription within 30 days of an infection-related hospitalization. Statistical analysis was performed on December 15, 2022. Exposures New use (no prior use any time before cohort entry) of oral haloperidol and atypical APMs (aripiprazole, olanzapine, quetiapine, risperidone, etc). Main Outcomes and Measures The primary outcome was APM discontinuation, defined as a gap of more than 15 days following the end of an APM dispensing. Survival analyses and Kaplan-Meier analyses were used. Results Our study population included 5835 patients. Of these individuals, 790 (13.5%) were new haloperidol users (mean [SD] age, 81.5 [6.7] years; 422 women [53.4%]) and 5045 (86.5%) were new atypical APM users (mean [SD] age, 79.8 [7.0] years; 2636 women [52.2%]). The cumulative incidence of discontinuation by 30 days after initiation was 11.4% (95% CI, 10.4%-12.3%) among atypical APM users and 52.1% (95% CI, 48.2%-55.7%) among haloperidol users (P < .001 for difference between haloperidol vs atypical APMs). We observed an increasing trend in discontinuation rates from 2004 to 2022 (5% increase [95% CI, 3%-7%] per year) for haloperidol users (adjusted hazard ratio, 1.05 [1.03-1.07]; P < .001) but not for atypical APM users (1.00 [0.99-1.01]; P = .67). Prolonged hospitalization and dementia were inversely associated with the discontinuation of haloperidol and atypical APMs. Conclusions and Relevance The findings of this cohort study suggest that the discontinuation rate of newly initiated APMs for delirium following infection-related hospitalization was lower in atypical APM users than in haloperidol users, with prolonged hospitalization and dementia as major associated variables. The discontinuation rate was substantially higher in recent years for haloperidol but not for atypical APMs.
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Affiliation(s)
- Yichi Zhang
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - James M. Wilkins
- Division of Geriatric Psychiatry, McLean Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lily Gui Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cassandra York
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vincent Wong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
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Wilkins JM, Locascio JJ, Gomez‐Isla T, Hyman BT, Blacker D, Forester BP, Okereke OI. Projection in Proxy Assessments of Everyday Preferences for Persons with Cognitive Impairment. Alzheimers Dement 2022. [DOI: 10.1002/alz.069379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- James M. Wilkins
- Harvard Medical School Boston MA USA
- McLean Hospital Belmont MA USA
| | - Joseph J Locascio
- Harvard Medical School Boston MA USA
- Massachusetts General Hospital Boston MA USA
| | - Teresa Gomez‐Isla
- Harvard Medical School Boston MA USA
- Massachusetts General Hospital Boston MA USA
| | - Bradley T. Hyman
- Harvard Medical School Boston MA USA
- Massachusetts General Hospital Charlestown MA USA
| | - Deborah Blacker
- Massachusetts General Hospital Boston MA USA
- Harvard University Boston MA USA
| | | | - Olivia I Okereke
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School Boston MA USA
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Wilkins JM, Locascio JJ, Gomez-Isla T, Hyman BT, Blacker D, Forester BP, Okereke OI. Longitudinal Changes in Neuropsychiatric Symptoms: Impact of Discrepancy in Everyday Preferences Between Persons With Cognitive Impairment and Their Care Partners. Am J Geriatr Psychiatry 2022; 30:619-623. [PMID: 34801383 PMCID: PMC8983425 DOI: 10.1016/j.jagp.2021.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/13/2021] [Accepted: 10/19/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Neuropsychiatric symptoms (NPS) of dementia are common and may be driven by inability of persons with cognitive impairment (CI) to communicate needs. We addressed the relevance of this unmet-needs model to burden of NPS among persons with milder CI. METHODS The sample included 48 dyads of persons with CI and their care partners. NPS were measured at baseline and follow-up (mean 486 days +/-107 SD). Mixed random and fixed effects longitudinal models were used to evaluate impact of discrepancies between persons with CI and their care partners in everyday preferences (baseline) on changes in NPS over time. RESULTS Higher levels of underestimation of "social engagement" preferences of persons with CI by care partners were associated with a higher average burden of NPS across all follow-up. CONCLUSIONS This study suggests that unmet-needs may be a useful construct for understanding etiology for NPS across the spectrum of severity of cognitive impairment.
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Affiliation(s)
- James M. Wilkins
- McLean Hospital, Belmont, MA; Harvard Medical School, Boston, MA.,Corresponding author. James M. Wilkins, MD, DPhil, Division of Geriatric Psychiatry, McLean Hospital, 115 Mill Street, Belmont, MA, 02478, USA, Phone: 617-855-3982; Fax: 617-855-3246,
| | - Joseph J. Locascio
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA,Harvard Catalyst Biostatistical Consulting, Harvard Catalyst/CTSA; Harvard Medical School, Boston, MA
| | - Teresa Gomez-Isla
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Bradley T. Hyman
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Deborah Blacker
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA,Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | | | - Olivia I. Okereke
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA,Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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Rosenberg PB, Outen JD, Amjad H, Burhanullah H, Vandrey R, Agronin M, Castaneda R, Isesalaya M, Walsh P, Ash ET, Cohen L, Wilkins JM, Harper DG, Forester BP. Pilot trial of dronabinol adjunctive treatment of agitation in Alzheimer's disease (THC‐AD). Alzheimers Dement 2021. [DOI: 10.1002/alz.052594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | - John D. Outen
- Johns Hopkins University School of Medicine Baltimore MD USA
| | - Halima Amjad
- Johns Hopkins University School of Medicine Baltimore MD USA
| | | | - Ryan Vandrey
- Johns Hopkins University School of Medicine Baltimore MD USA
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Wilkins JM. Longitudinal changes in neuropsychiatric symptoms: Impact of discrepancy in everyday preferences between people with cognitive impairment and their care partners. Alzheimers Dement 2021. [DOI: 10.1002/alz.052356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Wilkins JM. Reconsidering Gold Standards for Surrogate Decision Making for People with Dementia. Psychiatr Clin North Am 2021; 44:641-647. [PMID: 34763796 PMCID: PMC8597910 DOI: 10.1016/j.psc.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
As dementia progresses and cognitive function declines, surrogate decision making becomes increasingly prevalent. By convention, there is a hierarchical approach to proxy decision making beginning with known wishes, followed by a substituted judgment standard, and then a best-interests standard. For people with dementia, discrepancy in proxy assessments is common and associated with negative behavioral outcomes. Therefore, optimal approaches to proxy decision making for people with dementia should instead prioritize and implement options that encourage direct participation of persons with dementia and standards that explicitly rely on consideration of longitudinal changes in values and preferences for persons with dementia.
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Affiliation(s)
- James M. Wilkins
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA, USA,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Cohen LM, Ash E, Outen JD, Vandrey R, Amjad H, Agronin M, Burhanullah MH, Walsh P, Wilkins JM, Leoutsakos JM, Nowrangi MA, Harper D, Rosenberg PB, Forester BP. Study rationale and baseline data for pilot trial of dronabinol adjunctive treatment of agitation in Alzheimer's dementia (THC-AD). Int Psychogeriatr 2021:1-6. [PMID: 34629131 DOI: 10.1017/s1041610221001150] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Agitation is a common complication of Alzheimer's dementia (Agit-AD) associated with substantial morbidity, high healthcare service utilization, and adverse emotional and physical impact on care partners. There are currently no FDA-approved pharmacological treatments for Agit-AD. We present the study design and baseline data for an ongoing multisite, three-week, double-blind, placebo-controlled, randomized clinical trial of dronabinol (synthetic tetrahydrocannabinol [THC]), titrated to a dose of 10 mg daily, in 80 participants to examine the safety and efficacy of dronabinol as an adjunctive treatment for Agit-AD. Preliminary findings for 44 participants enrolled thus far show a predominately female, white sample with advanced cognitive impairment (Mini Mental Status Examination mean 7.8) and agitation (Neuropsychiatric Inventory-Clinician Agitation subscale mean 14.1). Adjustments to study design in light of the COVID-19 pandemic are described. Findings from this study will provide guidance for the clinical utility of dronabinol for Agit-AD. ClinicalTrials.gov Identifier: NCT02792257.
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Affiliation(s)
- Leah M Cohen
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA, USA
| | - Eleanor Ash
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA, USA
| | - John D Outen
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ryan Vandrey
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Halima Amjad
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marc Agronin
- Department of Mental Health and Clinical Research, Miami Jewish Health, Miami, FL, USA
| | - M Haroon Burhanullah
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Patricia Walsh
- Department of Psychiatry, North Shore Medical Center, Salem, MA, USA
| | - James M Wilkins
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jeannie-Marie Leoutsakos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Milap A Nowrangi
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Harper
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Paul B Rosenberg
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brent P Forester
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA, USA
- Harvard Medical School, Boston, MA, USA
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Wilkins JM, Locascio JJ, Gunther JM, Gomez-Isla T, Hyman BT, Blacker D, Forester BP, Okereke OI. Longitudinal differences in everyday preferences: Comparisons between people with cognitive impairment and their care partners. Int J Geriatr Psychiatry 2021; 37:10.1002/gps.5620. [PMID: 34498322 PMCID: PMC8901800 DOI: 10.1002/gps.5620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 09/01/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Persons with progressive cognitive impairment (CI) increasingly rely on surrogate decision-makers for everyday activities. Yet, little is known about changes in everyday preferences over time or about concordance between persons with CI and their care partners regarding longitudinal changes. METHODS The sample included 48 dyads of persons with CI (Clinical Dementia Rating Scale score ≥0.5) and their care partners. The Preferences for Everyday Living Inventory was used to assess importance of preferences among persons with CI at baseline and follow-up (mean 486 days). Care partners separately completed concurrent proxy assessments. Mixed random and fixed effects longitudinal models were used to evaluate changes in ratings and concordance levels between persons with CI and care partners. RESULTS There were significant gender differences regarding importance ratings of "autonomous choice" and "social engagement" preferences over time: women with CI rated these preferences as more important across time as a whole. Higher levels of neuropsychiatric symptoms were associated with less importance of "social engagement" preferences across time as a whole for persons with CI and a more negative discrepancy between persons with CI and care partner proxy assessments as time went on. CONCLUSION This study yields new insights into predictors of longitudinal change in everyday preferences among persons with CI and their care partners. Although preferences were largely stable over time, there is increasing support for the relationship between differences in "social engagement" preferences and neuropsychiatric symptoms, which may have implications for monitoring and/or treatment in the context of cognitive impairment.
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Affiliation(s)
- James M. Wilkins
- McLean Hospital, Belmont, MA; Harvard Medical School, Boston, MA
| | - Joseph J. Locascio
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
- Harvard Catalyst Biostatistical Consulting, Harvard Catalyst/CTSA; Harvard Medical School, Boston, MA
| | - Jeanette M. Gunther
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Teresa Gomez-Isla
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Bradley T. Hyman
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Deborah Blacker
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | | | - Olivia I. Okereke
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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13
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Wilkins JM, Okereke OI. Evaluating everyday preferences assessment over time between people with cognitive impairment and their care partners. Alzheimers Dement 2020. [DOI: 10.1002/alz.042285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
| | - Olivia I Okereke
- Massachusetts General Hospital Harvard Medical School Boston MA USA
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14
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Wilkins JM, Locascio JJ, Gunther JM, Yap L, Hyman BT, Blacker D, Forester BP, Okereke OI. Differences in Assessment of Everyday Preferences Between People With Cognitive Impairment and Their Care Partners: The Role of Neuropsychiatric Symptoms. Am J Geriatr Psychiatry 2020; 28:1070-1078. [PMID: 32144001 PMCID: PMC7415491 DOI: 10.1016/j.jagp.2020.01.189] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/15/2020] [Accepted: 01/28/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE As cognitive impairment progresses, people with dementia increasingly rely on surrogate decision-makers for everyday activities. Yet, little is known about concordance on everyday preferences between persons with cognitive impairment and their care partners. METHODS The sample included 69 dyads of persons with cognitive impairment (Clinical Dementia Rating Scale ≥0.5) and their care partners. We used the Preferences for Everyday Living Inventory (PELI) to assess preferences for activities and lifestyle choices among persons with cognitive impairment. The PELI was concurrently but separately administered to care partners, who answered as surrogate decision-makers. Factor analysis was used to ascertain factor structure of the PELI; reliability measures were computed within the sample. Paired sample t-tests were used to estimate differences in scores of corresponding PELI items for each factor. Multiple regression models were used to relate predictors, including neuropsychiatric symptoms, to agreement levels. RESULTS Four factors were identified from the PELI: autonomous choice, social engagement, personal growth, and keeping a routine. Significant participant-care partner discrepancy was found in "social engagement" preferences (e.g., regular contact with family, meeting new people, volunteering). Geriatric Depression Scale-15 score and care partner sex were significantly associated with participant-care partner discrepancies in "social engagement" preferences. CONCLUSION This study yields new insights regarding the most important preferences for persons with cognitive impairment and clarifies a path to optimizing surrogate decision-making around everyday preferences by highlighting areas of apparent disagreement and identifying potential predictors of discrepancy.
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Affiliation(s)
- James M. Wilkins
- McLean Hospital, Belmont, MA; Harvard Medical School, Boston, MA
| | - Joseph J. Locascio
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School; Boston, MA
| | - Jeanette M. Gunther
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School; Boston, MA
| | - Liang Yap
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School; Boston, MA
| | - Bradley T. Hyman
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School; Boston, MA
| | - Deborah Blacker
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School; Boston, MA,Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | | | - Olivia I. Okereke
- Massachusetts Alzheimer’s Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School; Boston, MA,Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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Wilkins JM, Nowak LM, Forester BP. Disparities in the Luxury of Distance for COVID-19 Care. Am J Geriatr Psychiatry 2020; 28:896-897. [PMID: 32444322 PMCID: PMC7198180 DOI: 10.1016/j.jagp.2020.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 04/24/2020] [Accepted: 04/25/2020] [Indexed: 11/17/2022]
Affiliation(s)
- James M Wilkins
- McLean Hospital (JMW, BPF), Belmont, MA; Harvard Medical School (JMW, BPF), Boston, MA.
| | | | - Brent P Forester
- McLean Hospital (JMW, BPF), Belmont, MA; Harvard Medical School (JMW, BPF), Boston, MA
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Wilkins JM, Forester BP. Informed consent, therapeutic misconception, and clinical trials for Alzheimer's disease. Int J Geriatr Psychiatry 2020; 35:430-435. [PMID: 31895474 PMCID: PMC7141972 DOI: 10.1002/gps.5262] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/21/2019] [Indexed: 11/07/2022]
Affiliation(s)
- James M. Wilkins
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Brent P. Forester
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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17
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Wilkins JM. Reflections on Home. J Am Geriatr Soc 2020; 68:889-890. [DOI: 10.1111/jgs.16355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/15/2020] [Accepted: 01/17/2020] [Indexed: 11/25/2022]
Affiliation(s)
- James M. Wilkins
- Division of Geriatric Psychiatry McLean Hospital Belmont Massachusetts
- Department of Psychiatry Harvard Medical School Boston Massachusetts
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Wilkins JM, Goldstein EK, Forester BP. Characteristics of Hospice Referrals From an Inpatient Geriatric Psychiatry Unit. Am J Geriatr Psychiatry 2019; 27:162-166. [PMID: 30583918 DOI: 10.1016/j.jagp.2018.11.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/17/2018] [Accepted: 11/22/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Geriatric psychiatrists who treat neuropsychiatric symptoms of dementia are in the unique position of offering palliation to people with terminal illness in whom neuropsychiatric symptoms may be indicators of the illness's end stage (e.g., feeding problems). Little is known, however, about the characteristics of hospice referrals from inpatient geriatric psychiatry units. METHODS This was a retrospective chart review of patients with dementia admitted to an inpatient geriatric psychiatry unit and referred to hospice on discharge. RESULTS Patients were referred to hospice because of feeding problems, with oral intake insufficient to sustain life. Most patients (78%) died within 31 days of discharge, and all patients (100%) died within 6 months of discharge. CONCLUSION The results from this study support a symptom-based approach to hospice referral for people with dementia, as opposed to prognostic estimation, where certain symptom clusters may indicate a more rapidly progressing course.
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Affiliation(s)
- James M Wilkins
- Division of Geriatric Psychiatry (JMW, EKG, BPF), McLean Hospital, Belmont, MA; Department of Psychiatry (JMW, BPF), Harvard Medical School, Boston.
| | | | - Brent P Forester
- Division of Geriatric Psychiatry (JMW, EKG, BPF), McLean Hospital, Belmont, MA; Department of Psychiatry (JMW, BPF), Harvard Medical School, Boston
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Wilkins JM. Narrative Interest Standard: A Novel Approach to Surrogate Decision-Making for People With Dementia. Gerontologist 2018; 58:1016-1020. [PMID: 29617766 DOI: 10.1093/geront/gnx107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 05/31/2017] [Indexed: 11/13/2022] Open
Abstract
Dementia is a common neurodegenerative process that can significantly impair decision-making capacity as the disease progresses. When a person is found to lack capacity to make a decision, a surrogate decision-maker is generally sought to aid in decision-making. Typical bases for surrogate decision-making include the substituted judgment standard and the best interest standard. Given the heterogeneous and progressive course of dementia, however, these standards for surrogate decision-making are often insufficient in providing guidance for the decision-making for a person with dementia, escalating the likelihood of conflict in these decisions. In this article, the narrative interest standard is presented as a novel and more appropriate approach to surrogate decision-making for people with dementia. Through case presentation and ethical analysis, the standard mechanisms for surrogate decision-making for people with dementia are reviewed and critiqued. The narrative interest standard is then introduced and discussed as a dementia-specific model for surrogate decision-making. Through incorporation of elements of a best interest standard in focusing on the current benefit-burden ratio and elements of narrative to provide context, history, and flexibility for values and preferences that may change over time, the narrative interest standard allows for elaboration of an enriched context for surrogate decision-making for people with dementia. More importantly, however, a narrative approach encourages the direct contribution from people with dementia in authoring the story of what matters to them in their lives.
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Affiliation(s)
- James M Wilkins
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, Massachusetts.,Department of Psychiatry, Massachusetts General Hospital, Boston.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
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Affiliation(s)
- James M Wilkins
- Division of Geriatric Psychiatry, McLean Hospital, 115 Mill Street, Belmont, MA, 02478, USA.
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
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Wilkins JM. More Than Capacity: Alternatives for Sexual Decision Making for Individuals With Dementia. GERONT 2015; 55:716-23. [DOI: 10.1093/geront/gnv098] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 05/28/2015] [Indexed: 11/13/2022] Open
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Wilkins JM, Southam L, Mustafa Z, Chapman K, Loughlin J. Association of a functional microsatellite within intron 1 of the BMP5 gene with susceptibility to osteoarthritis. BMC Med Genet 2009; 10:141. [PMID: 20021689 PMCID: PMC2807860 DOI: 10.1186/1471-2350-10-141] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Accepted: 12/19/2009] [Indexed: 01/28/2023]
Abstract
Background In a previous study carried out by our group, the genotyping of 36 microsatellite markers from within a narrow interval of chromosome 6p12.3-q13 generated evidence for linkage and for association to female hip osteoarthritis (OA), with the most compelling association found for a marker within intron 1 of the bone morphogenetic protein 5 gene (BMP5). In this study, we aimed to further categorize the association of variants within intron 1 of BMP5 with OA through an expanded genetic association study of the intron and subsequent functional analysis of associated polymorphisms. Methods We genotyped 18 common polymorphisms including 8 microsatellites and 9 single nucleotide polymorphisms (SNPs) and 1 insertion/deletion (INDEL) from within highly conserved regions between human and mouse within intron 1 of BMP5. These markers were then tested for association to OA by a two-stage approach in which the polymorphisms were initially genotyped in a case-control cohort comprising 361 individuals with associated polymorphisms (P ≤ 0.05) then genotyped in a second case-control cohort comprising 1185 individuals. Results Two BMP5 intron 1 polymorphisms demonstrated association in the combined case-control cohort of 1546 individuals (765 cases and 781 controls): microsatellite D6S1276 (P = 0.018) and SNP rs921126 (P = 0.013). Functional analyses in osteoblastic, chondrocytic, and adipocytic cell lines indicated that allelic variants of D6S1276 have significant effects on the transcriptional activity of the BMP5 promoter in vitro. Conclusion Variability in gene expression of BMP5 may be an important contributor to OA genetic susceptibility.
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Affiliation(s)
- James M Wilkins
- University of Oxford, Institute of Musculoskeletal Sciences, Botnar Research Centre, Nuffield Orthopaedic Centre, Oxford, OX3 7LD, UK.
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Egli RJ, Southam L, Wilkins JM, Lorenzen I, Pombo-Suarez M, Gonzalez A, Carr A, Chapman K, Loughlin J. Functional analysis of the osteoarthritis susceptibility-associated GDF5 regulatory polymorphism. ACTA ACUST UNITED AC 2009; 60:2055-64. [PMID: 19565498 DOI: 10.1002/art.24616] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Single-nucleotide polymorphism (SNP) rs143383 (T to C) in the 5'-untranslated region (5'-UTR) of GDF5 has recently been reported to be associated with osteoarthritis (OA) susceptibility, with lower expression of the risk-associated T allele observed in vitro and in vivo. The in vivo studies were performed on cartilage tissue from OA patients. The present study was undertaken to expand the analysis of the effect of this SNP on GDF5 allelic expression to more joint tissue types, to investigate for cis and trans factors that interact with the SNP, and to examine novel cis-acting GDF5 regulatory polymorphisms. METHODS Tissue samples were collected from OA patients undergoing joint replacement of the hip or knee. Nucleic acid was extracted, and, using rs143383 and an assay that discriminates and quantifies allelic expression, the relative amount of GDF5 expression from the T and C alleles was measured. Additional common variants in the GDF5 transcript sequence were interrogated as potential regulatory elements using allelic expression and luciferase reporter assays, and electrophoretic mobility shift assays were used to search for trans factors binding to rs143383. RESULTS We observed a consistent allelic expression imbalance of GDF5 in all tissues tested, implying that the functional effect mediated by rs143383 on GDF5 expression is joint-wide. We identified a second polymorphism, located in the 3'-UTR of GDF5, that influenced allelic expression of the gene independent of rs143383. Finally, we observed differential binding of deformed epidermal autoregulatory factor 1 (DEAF-1) to the 2 alleles of rs143383. CONCLUSION These findings show that the OA susceptibility mediated by polymorphism in GDF5 is not restricted to cartilage, emphasizing the need to consider the disease as involving the whole joint. The existence of an additional cis-acting regulatory polymorphism highlights the complexity of the regulation of expression of this important OA susceptibility locus. DEAF-1 is a trans-acting factor that merits further investigation as a potential tool for modulating GDF5 expression.
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Southam L, Rodriguez-Lopez J, Wilkins JM, Pombo-Suarez M, Snelling S, Gomez-Reino JJ, Chapman K, Gonzalez A, Loughlin J. An SNP in the 5′-UTR of GDF5 is associated with osteoarthritis susceptibility in Europeans and with in vivo differences in allelic expression in articular cartilage. Hum Mol Genet 2007; 16:2226-32. [PMID: 17616513 DOI: 10.1093/hmg/ddm174] [Citation(s) in RCA: 146] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
A compelling genetic association with osteoarthritis (OA) of a functional SNP (rs143383, T/C) in the 5'-UTR of the GDF5 gene was recently reported in case-control cohorts from Japan and China. GDF5 is a pro-chondrogenic growth factor. The T-allele frequency of the gene was elevated in cases, with an odds ratio (OR) of 1.79, and in vitro functional studies demonstrated that this allele mediated a moderate but significant reduction in the activity of the GDF5 promoter in several cell lines. Our initial objective was to assess whether the SNP was also associated with OA in a broad European population by genotyping the SNP in 2487 cases and 2018 age-matched controls from the UK and Spain. The T-allele was associated with OA (P = 0.03, OR = 1.10) as was carrier status for this allele (P = 0.004, OR = 1.28), demonstrating that the SNP is associated with OA in two diverse ethnic groups, Asians and Europeans. We subsequently assessed the functional effect of the SNP on GDF5 allelic expression using RNA extracted from the cartilage of OA patients who had undergone joint-replacement surgery. The associated T-allele showed up to a 27% reduction in expression relative to the C-allele (P = 0.00007), revealing that the functional effect mediated by SNP rs143383 on GDF5 expression is active in patients who have severe disease up to the point at which they require surgery. A small but persistent imbalance of GDF5 expression throughout life therefore appears to render an individual more susceptible to OA.
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Abstract
Variability in cis-regulation of gene expression has been implicated in the phenotypic manifestation of complex traits including common, multifactorial diseases. The differential expression of alleles due to polymorphism in cis-regulatory elements is common in the human genome, but there is a paucity of information about the context specificity of these control elements. In this study, we examined the differential allelic expression (DAE) of BMP5 in human mesenchymal tissues obtained from 16 donors undergoing joint replacement for treatment of osteoarthritis. We observed significant differences in BMP5 allelic output, with allelic ratios greater than 4:1 (P < 10(-20)) in the tissues of some donors. We also discovered a significant variability in allelic expression within the different tissues of donors. For 12 of our donors, we examined the allelic expression of BMP5 in two different regions of cartilage: cartilage adjacent to the site of the osteoarthritic lesion and cartilage distal from the lesion. Five of these 12 donors demonstrated highly significant differences (P < or = 10(-8)) in allelic expression between the different regions of their cartilage. Using DAE as a phenotype, we attempted to map tissue-specific cis-regulatory polymorphisms, and we identified a single nucleotide polymorphism located downstream of BMP5, which was significantly associated with DAE in some but not all of the examined tissues. These findings suggest that allelic expression can be highly context specific and that when interrogating the cis-regulatory control of a particular gene, one cannot necessarily assume that allelic expression is conserved across different tissues or even across different regions of the same tissue.
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Affiliation(s)
- James M Wilkins
- University of Oxford, Institute of Musculoskeletal Sciences, Botnar Research Centre, Nuffield Orthopaedic Centre, Oxford OX3 7LD, UK.
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Lasswell WL, Weber SS, Wilkins JM. In vitro interaction of neuroleptics and tricylic antidepressants with coffee, tea, and gallotannic acid. J Pharm Sci 1984; 73:1056-8. [PMID: 6149298 DOI: 10.1002/jps.2600730809] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The in vitro interaction of selected drugs with coffee, tea, gallic acid, and gallotannic acid was examined by mixing solutions of drug with each of these four preparations. Results of these experiments indicate that significant precipitation occurs for a variety of agents, including several phenothiazines, amitriptyline, haloperidol, imipramine, and loxapine. The strong complex which is formed between these drugs and tannins is probably the basis of the interaction of these drugs with coffee and tea. Although precipitates did occur with a number of neuroleptics, two members of this drug class, thiothixene and molindone, failed to interact with the solutions used.
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