Using Audio Computer-Assisted Self-Interviewing and Interactive Voice Response to Measure Elder Mistreatment in Older Adults: Feasibility and Effects on Prevalence Estimates

Demographic trends indicate an aging population, highlighting the importance of collecting valid survey data from older adults. One potential issue when surveying older adults is use of technology to collect data on sensitive topics. Survey technologies like A-CASI and IVR have not been used with older adults to measure elder mistreatment. We surveyed 903 adults age 60 and older in Allegheny County, Pennsylvania (U.S.) with random assignment to one of four survey modes: (1) CAPI, (2) A-CASI, (3) CATI; and (4) IVR. We assessed financial, psychological, and physical mistreatment, and examined feasibility of A-CASI and IVR, and effects on prevalence estimates relative to CAPI and CATI. Approximately 83% of elders randomized to A-CASI/IVR used each technology, although 28% of respondents in the A-CASI condition refused to use headphones and read the questions instead. A-CASI produced higher six month prevalence rates of financial and psychological mistreatment than CAPI. IVR produced higher six month prevalence rates of psychological mistreatment than CATI. We conclude that, while IVR may be useful, A-CASI offers a more promising approach to the measurement of elder mistreatment.

Detection and management of cognitive impairment in primary care: The Steel Valley Seniors Survey

OBJECTIVES

To identify characteristics of older primary care patients who were cognitively impaired and who underwent mental status testing by their physicians.

DESIGN

Cross-sectional and retrospective analysis.

SETTING

Seven small-town primary care practices.

PARTICIPANTS

A total of 1,107 patients with a mean+/-standard deviation age of 76.3+/-6.6, screened using the Mini-Mental State Examination (MMSE); medical records reviewed.

MEASUREMENTS

Demographics, MMSE, medical record information. Odds ratios (OR) with 95% confidence intervals (CI), adjusted for age, sex, and education.

RESULTS

Thirty-one percent of the sample had MMSE scores of less than 25. Among these patients, physicians documented memory loss in only 23% which was significantly more often than in the higher scoring group (OR=1.9, 95% CI=1.3-2.8), basic activity of daily living (ADL) impairment in 7.9% (OR=2.4, 95% CI=1.3-4.4), instrumental ADL (IADL) impairment in 6.7% (OR=2.2, 95% CI=1.1=4.2), dementia in 12.2% (OR=3.7, 95% CI=2.0-6.8), and prescription of cholinesterase inhibitors in 7.6% (OR=4.4, 95% CI=1.9-10.2). Physicians recorded mental status testing largely in patients with research MMSE scores of 24 to 28, significantly more often when they also documented memory loss (OR=3.8, 95% CI=2.5-5.6) or impaired IADLs (OR=2.7, 95% CI=1.4-5.2), diagnosed dementia (OR=4.9, 95% CI=2.8-8.6), referred to specialists (OR=6.3, 95% CI=2.5-16.2) or social services (OR=3.6, 95% CI=1.8-7.3), or prescribed cholinesterase inhibitors (OR=8.5, 95% CI=4.2-17.5).

CONCLUSION

Physicians noted impairment in a minority of impaired patients. They tested mental status in those with documented cognitive and functional difficulties, in very mildly impaired patients, and in those for whom they intervened.

Elders with dementia living in the community with and without caregivers: an epidemiological study

BACKGROUND

Previous studies of dementia and family caregiving have focused on individuals seeking diagnosis and treatment, and have rarely been conducted in representative community samples. Identifying demented individuals participating in a community survey, we determined (a) the factors associated with demented elderly living alone; (b) the factors associated with the demented elderly having caregivers; (c) the factors associated with increased levels of burden among caregivers of persons with dementia.

POPULATION AND METHODS

During an epidemiological survey of a mostly rural U.S. community, the authors identified 116 noninstitutionalized elderly individuals with dementia. These individuals were classified into those living alone and those living with others; both groups were further classified into those with and without identifiable family caregivers. Characteristics of both caregivers and care recipients were examined.

RESULTS

Approximately a third of the subjects with dementia lived alone, and only half of them had caregivers. The average age of the caregivers was 67.4 years, and 73% of them were women. Almost half of the caregivers were spouses, whereas almost a third were offspring, of the demented individuals. Over two thirds of caregivers lived with the subjects. Female caregivers were significantly younger than male caregivers. Multivariate analyses revealed that subjects with dementia who were living alone were independently and significantly more likely to be women and to have dementias of shorter duration, lesser severity, and lesser functional impairment than those living with others. Demented subjects with caregivers were more likely to have greater dementia severity, functional impairment, and cognitive impairment and more current cognitive and behavioral symptoms than those without caregivers. Demented subjects whose caregivers reported higher levels of burden were more likely to be women and to have greater dementia severity, functional impairment, and cognitive impairment and more current symptoms than those whose caregivers had no/minimal burden.

CONCLUSIONS

These results draw attention to the problems of persons with dementia living alone, particularly those without caregivers. Our data also provide epidemiological confirmation of previous clinical/volunteer studies of dementia caregiving, as well as a preliminary assessment of need in the community at large. Living arrangements and caregiver issues should be taken into account when planning services for the elderly.

Combined pharmacotherapy and psychotherapy in the acute and continuation treatment of elderly patients with recurrent major depression: a preliminary report

OBJECTIVE

The authors examined the rate of response to the combination of nortriptyline and interpersonal psychotherapy for acute and continuation treatment of elderly patients with recurrent major depression.

METHOD

The subjects were 73 elderly patients, 61 of whom completed treatment. Nortriptyline steady-state blood levels were maintained at 80-120 ng/ml, and interpersonal psychotherapy was administered weekly for 9.1 weeks (medium) of acute therapy and was decreased from biweekly to triweekly during 16 weeks of continuation therapy. During acute treatment nonresponding patients also received brief adjunctive pharmacotherapy with lithium or perphenazine.

RESULTS

Of the 61 subjects given adequate trials of nortriptyline and interpersonal psychotherapy, 48 (78.7%) achieved full remission (Hamilton depression rating of 10 or lower over 16 weeks of continuation therapy), 10 patients (16.4%) did not respond (Hamilton rating never below 15), and three achieved only partial remission (Hamilton rating of 11-14). Early versus late onset was not associated with a difference in response rate. During the placebo-controlled, double-blind transition to maintenance therapy, 19 (76.0%) of the 25 patients randomly assigned to placebo maintenance conditions showed continued recovery and six relapsed. None of the 24 patients assigned to nortriptyline conditions relapsed.

CONCLUSIONS

Use of nortriptyline plus interpersonal psychotherapy for 9.1 weeks (median) of acute and 16 weeks of continuation therapy appears to be associated with good response and relatively low attrition but about a 25% chance of relapse during double-blind discontinuation of nortriptyline. These data require confirmation in a controlled clinical trial of acute and continuation therapy.

Open-trial maintenance pharmacotherapy in late-life depression: survival analysis

We report preliminary findings from an ongoing, open trial of maintenance nortriptyline pharmacotherapy in 27 elderly depressed patients (median trial length: 18 months). While patients were on maintenance nortriptyline (mean dose: 50 mg/day) with steady-state plasma levels in the range of 50-150 ng/ml, 58% of Q-6 monthly ratings on the Hamilton Rating Scale for Depression have been 10 or lower, Folstein Mini-Mental State ratings have remained above 27, and a minimal level of side effects with no increase over time has been observed. Four of 27 patients (14.8%) have suffered recurrences and have required rehospitalization at 6, 9, 10, and 13 months. Survival analysis showed an 85% survival rate (without recurrence) at 12 months and 81.5% at 18 months. Mean survival time without recurrence is 21.3 months to date. Although our pilot experience with maintenance nortriptyline in late-life depression appears more favorable than outcomes reported in earlier naturalistic studies (where no attempt was made to keep patients in systematic maintenance therapy), the need for controlled studies of maintenance therapies in late-life depression is nonetheless underscored by the current data and other naturalistic data from the United Kingdom.

Caregiving strain and the desire to institutionalize family members with Alzheimer's disease. Possible predictors and model development

This research explores whether the strain experienced by caregivers of relatives with Alzheimer's disease will be strongly related to the desire of families to institutionalize their older members. The desire of a caregiver to institutionalize a patient with Alzheimer's disease was found to be greater when the caregiver experiences increased strain or burden, when a patient is widowed, when there is more physical labor involved in caregiving tasks, and when the patient lives alone. Intensity of family strain (or felt stress) can best be predicted by the availability to the caregiver of social support: Less support implies more strain. However, for male caregiving groups and for all black caregivers, strain does not play a significant role in predicting the desire to institutionalize.

Community-based geriatric assessment

A comprehensive review of the multidisciplinary functional assessment and treatment of 800 patients seen at a community-based geriatric assessment center was performed to profile clinical characteristics of patients attending such a program and to evaluate possible predictors of institutionalization. The most common problems addressed were senile dementia (46%), hypertension (31%), clinically significant depression (30%), and burdened caregiver (24%). More than 90% of patients were able to remain in the community after multidisciplinary treatment of their problems and marshalling of support services. The most potent predictors of institutionalization in rank order of predictive value were: falls or unstable gait, senile dementia, caregiver strain, lack of support services, and moderate to severe impairment of ability to perform activities of daily living (multiple R = 0.45; P = .001). Advantages and impediments to community-based assessment are discussed.

Developing a curriculum in psychogeriatrics

Psychiatric problems are rampant among the aged, yet the psychiatric profession has not developed sufficient resources for training the necessary number of practitioners able and willing to treat elderly psychiatric patients. The management of psychiatric problems in old age differs substantially from that in younger age groups. The elderly patient is likely to have multiple needs and to require diverse services. Fundamental goals in training geriatric psychiatrists should focus on differential diagnosis and treatment, pharmacologic issues, consultation, community resources, and psychiatric, medical, and psychosocial aspects of care. The authors describe a curriculum tailored to meet these goals.