Disability Experiences and Perspectives Regarding Reproductive Decisions, Parenting, and the Utility of Genetic Services: a Qualitative Study

Genetic counselors adopt seemingly contradictory roles: advocating for individuals with genetic conditions while offering prenatal diagnosis and the option of selective termination to prevent the birth of a child with a disability. This duality contributes to the tension between the disability and clinical genetics communities. Varying opinions exist amongst the disability community: some value genetic services while others are opposed. However, there is limited research exploring the opinions of individuals with a disability regarding issues related to reproduction and genetic services in the context of personal experience. This exploratory qualitative study involved interviews with seven women and three men who self-identify as having a disability. We sought to gain their perspectives on experiences with disability, thoughts about reproduction and parenting, and perceptions of genetic services. Transcripts of the interviews were analyzed thematically using qualitative content analysis. Data analysis showed that societal views of disability affected the lived experience and impacted reproductive decision-making for those with a disability. It also showed differing interest in genetic services. Concerns about the perceived collective implications of genetic services were also raised. These findings contribute to the understanding of the disability perspective toward reproductive decision-making and genetic services. A further goal is to promote a meaningful dialogue between the genetics and disability communities, with the potential to enhance the genetic and reproductive care provided to individuals with disabilities.

Admissions to hospital with exacerbations of chronic obstructive pulmonary disease: Effect of age related factors and service organisation

BACKGROUND

Exacerbations of chronic obstructive pulmonary disease (COPD) have a high rate of mortality which gets worse with advancing age. It is unknown whether this is due to age related deficiencies in process of care. A study was undertaken in patients with COPD exacerbations admitted to UK hospitals to assess whether there were age related differences in the process of care that might affect outcome, and whether different models of care affected process and outcome.

METHODS

247 hospital units audited activity and outcomes (inpatient death, death within 90 days, length of stay (LOS), readmission within 90 days) for 40 consecutive COPD exacerbation admissions in autumn 2003. Logistic regression methods were used to assess relationships between process and outcome at p < 0.001.

RESULTS

7514 patients (36% aged > or = 75 years) were included. Patients aged > or = 75 years were less likely to have blood gases documented, to have FEV1 recorded, or to be given systemic corticosteroids. Those admitted under care of the elderly (CoE) physicians were less likely to enter early discharge schemes or to receive non-invasive ventilation when acidotic. Overall inpatient and 90 day mortality was 7.4% and 15.3%, respectively. Inpatient and 90 day adjusted odds mortality rates for those aged > or = 85 years (versus < or = 65 years) were 3.25 and 2.54, respectively. Mortality was unaffected by admitting physician (CoE v general v respiratory). Age predicted LOS but not readmission. Age related deficiencies in process of care did not predict inpatient or 90 day mortality, readmission, or LOS.

CONCLUSIONS

Management of COPD exacerbations varies with age in UK hospitals. Inpatient and 90 day mortality is approximately three times higher in very elderly patients with a COPD exacerbation than in younger patients. Age related deficiencies in the process of care were not associated with mortality, but it is likely that they represent poorer quality of care and patient experience. Recommended standards of care should be applied equally to elderly patients with an exacerbation of COPD.

UK National COPD Audit 2003: Impact of hospital resources and organisation of care on patient outcome following admission for acute COPD exacerbation

BACKGROUND

Acute chronic obstructive pulmonary disease (COPD) exacerbations use many hospital bed days and have a high rate of mortality. Previous audits have shown wide variability in the length of stay and mortality between units not explained by patient factors. This study aimed to explore associations between resources and organisation of care and patient outcomes.

METHODS

234 UK acute hospitals each prospectively identified 40 consecutive acute COPD admissions, documenting process of care and outcomes from a retrospective case note audit. Units also completed a resources and organisation of care proforma.

RESULTS

Data for 7529 patients were received. Inpatient mortality was 7.4% and mortality at 90 days was 15.3%; the readmission rate was 31.4%. Mean length of stay for discharged patients was 8.7 days (median 6 days). Wide variation was observed in all outcomes between hospitals. Both inpatient mortality (odds ratio (OR) 0.67, CI 0.50 to 0.90) and 90 day mortality (OR 0.75, CI 0.60 to 0.94) were associated with a staff ratio of four or more respiratory consultants per 1000 hospital beds. The length of stay was reduced in units with more respiratory consultants, better organisation of care scores, an early discharge scheme, and local COPD management guidelines.

CONCLUSIONS

Units with more respiratory consultants and better quality organised care have lower mortality and reduced length of hospital stay. This may reflect unit resource richness. Dissemination of good organisational practice and recruitment of more respiratory specialists offers the potential for improved outcomes for hospitalised COPD patients.

A 25-year longitudinal, comparison study of the outcome of depression

BACKGROUND

There is still a relative paucity of information about the long-term course of depression.

METHODS

Consecutive patients admitted to a teaching hospital psychiatry unit with symptoms of depression, previously assessed at 6 months and 2, 5 and 15 years after index admission, were reviewed at 25 years (N = 49, including eight informants of deceased probands, of an original 145 with major depression (DEPs)). Prospective psychiatric (N = 22) and retrospective surgical (N = 50) control groups assessed after 25 years were used for comparison.

RESULTS

A further decade of follow-up confirmed the chronicity of depression. Of depressed patients (DEPs) followed for the full 25-year-period only 12% of the 49 original DEPs recovered and remained continuously well, 84% experienced recurrences, 2% experienced an unremitting course and another 2% died by suicide. Note that in the first 15-year-period 6% (9/145 DEPs) committed suicide, a further 38 died and 32 were lost to follow-up. They experienced an average of three episodes of depression over the 25 years. In the decade since the 15-year follow-up, 27% improved in clinical outcome (including four of five previously chronically depressed patients), 55% remained unchanged and 18% worsened; and the number of episodes per year declined. Patients initially diagnosed with neurotic or endogenous depression had similar long-term outcomes. The criteria for a current DSM-III-R disorder were met by 37% of DEPs, including 11% with depression or dysthymia. On the global assessment of functioning scale 78% of the DEPs had some impairment compared to 62% of psychiatric controls and 40% of surgical controls.

CONCLUSION

Even after 25 years, severe depressive disorders appear to have poor long-term outcomes. Patients with chronic outcomes over 15 years can improve when followed over longer periods.

Education, activity, health, blood pressure and apolipoprotein E as predictors of cognitive change in old age: a review

BACKGROUND

Cross-sectional studies have identified a number of health and lifestyle factors that correlate with cognitive function in old age. It is important to know whether these factors also predict change in cognitive function over time.

OBJECTIVE

To evaluate published findings on genetic, health and lifestyle predictors of cognitive change in late adulthood.

METHODS

Studies reporting data on education, health, blood pressure, activity and apolipoprotein E (APOE) as predictors of cognitive change were reviewed. A total of 34 studies were identified that reported data on these predictors. The average follow-up period of studies reviewed was 7.68 years.

RESULTS

Results showed that education, hypertension, objective indices of health and cardiovascular disease, and APOE were associated with cognitive change. Results regarding the effect of physical activity on cognitive change were inconclusive.

CONCLUSION

Despite the lack of data on some predictors, the longitudinal trends are generally consistent with cross-sectional findings on predictors of cognitive performance in old age. More research is required to compare the influence of predictors on different types of cognitive abilities.

Construct overlap in resource theories of memory aging. Commentary

This article evaluates the conceptual status of working memory, processing speed, executive function and sensory function as mediational constructs to explain memory aging. The main difficulty for these mediational constructs is that they may not be independent. Mediational constructs may overlap with each other or with the dependent variable due to theoretical, substantive or methodological reasons. It is argued that sensory function has an advantage over processing speed, working memory and executive function as a mediational construct because it is non-cognitive. The problem of construct overlap is relevant to both cross-sectional and longitudinal studies. Further research is required to evaluate the relative importance of mediational constructs in theories of memory aging, general intellectual aging and dementia.

Recall of depressive episode 25 years previously

BACKGROUND

Lifetime rates of depression reported in epidemiological surveys are generally only twice the 12 month rates. Either people forget the symptoms of depression or many people who have a depressive episode remain depressed for many years. Both may be true. There is a need to examine the long-term clinical validity of interviews that are used to make lifetime diagnoses.

METHODS

Forty-five patients who were part of a long-term follow-up study of depression were interviewed 25 years after the index episode. The diagnoses from the original, fully structured interviews were compared with the responses people made for that period when interviewed using the CIDI 25 years later.

RESULTS

Twenty-seven patients met CIDI DSM-III-R criteria for depression at index episode. At the 25 year follow-up, 19 of the 27 reported the essential symptoms of 'depression or loss of interest' being present at the index time, and in 14 of the 27 the depressive symptoms recalled met criteria for DSM-III-R major depressive episode at that time.

CONCLUSIONS

Seventy per cent of people who were hospitalized for a major depressive episode can recall being depressed but only half can recall sufficient detail to satisfy the diagnostic criteria when interviewed 25 years later. As depressive episodes, especially those severe enough to warrant admission, are recalled better than many other diagnoses, one must be cautious about the lifetime rates for mental disorders reported in retrospective epidemiological surveys.

Psychosocial stressors, physical illness and the spectrum of depression in elderly inpatients

OBJECTIVES

To describe all elderly patients hospitalised with principal and secondary diagnoses of depression, and to determine whether a relationship can be demonstrated between psychosocial stressors, physical illness and type of depression.

METHOD

A retrospective chart review of elderly patients admitted to a general hospital psychiatry ward over a 7-year period with principal or secondary diagnoses of depression was undertaken. Four broad diagnostic categories of depression were used: major depression, psychotic depression, minor depression, and organic depression. Chief outcome measures were: number of medical diagnostic categories, presence of psychosocial stressors, global clinical improvement, and length of stay.

RESULTS

Of 228 patients admitted with depression (194 principal diagnoses and 34 secondary diagnoses), 100 had major depression, 47 psychotic depression, 48 minor depression and 33 organic depression. Psychiatric comorbidity occurred in 70%, about half of which was due to organic brain syndrome. Patients with psychotic depression had the fewest medical problems and those with organic depression the most, while patients with minor depression had the highest rate of family and marital problems, comorbid personality dysfunction and suicide attempts. Patients with psychotic depression had the longest admissions, while those with minor depression had the shortest. Overall, 89% showed significant clinical improvement.

CONCLUSIONS

Elderly inpatients have a wide spectrum of depressive disorders with different psychosocial, medical and treatment profiles. Future studies of depression in old age should include all patients with clinical depression.

Type 2 diabetes. Patient practices, and satisfaction with GP care

OBJECTIVE

To document patients' practices and management of DM2, their satisfaction with diabetes care and their quality of life and functional status.

DESIGN

Anonymous questionnaire completed by 467 patients recruited by 204 GPs in 124 practices in the Perth metropolitan area.

RESULTS

Patients reported an adequate amount of monitoring for stable DM2. However, they lacked awareness of diabetes risk factors and complications from which they already suffered. Some 90% of patients reported a high level of satisfaction with GP care and only 2.4% of patients had more than a moderate degree of functional disability.

CONCLUSION

Patients have a high level of satisfaction about the diabetes care received from their general practitioner. However, they lack awareness of their risk factors and complications of diabetes. A simple strategy is proposed to improve these deficits and to share the responsibility for diabetes care between patient and doctor.

Physiologic, health and lifestyle factors associated with femoral neck bone density in older women

Three hundred eleven women aged between 60 and 91 years (mean age 72.2) who were randomly recruited from the community underwent bone density assessments of the femoral neck. Two complementary multivariate techniques were used to assess the relationships between femoral neck bone density and a range of anthropometric, health, and lifestyle measures. Stepwise multiple linear regression analysis revealed age, weight, height, quadriceps strength, and lifelong smoking to be variables that independently and significantly explained part of the variance in femoral neck bone density within the group. Multiple logistic regression revealed that after adjusting for established predictors of bone mineral density, age, height, and weight, reduced quadriceps strength, lifelong smoking, and little childhood activity were significantly associated with low bone density (< 0.70 g/cm2), whereas superior quadriceps strength, nonsmoking, and high levels of current physical activity were significantly associated with high bone density (> 0.84 g/cm2). In contrast, current calcium intake was not significantly associated with bone density. The study findings highlight possible public health initiatives for minimizing age-related femoral neck bone loss in older women.

Management of type 2 diabetes in Western Australian metropolitan general practice

The purpose of this study was: (1) to record GP opinions, practices and outcomes for the care of Type 2 Diabetes Mellitus (DM2), (2) compare practice facilities and process of care with a criterion of recommended competent care and (3) determine if there were any differences between vocationally registered and non-vocationally registered GPs. A random sample of 204 metropolitan doctors from 124 practices was selected and an audit performed on 467 of their patient records. GPs pursued good blood sugar control and advocated lifestyle changes before hypoglycaemic drugs. Over 80% regard uncomplicated DM2 as a condition for general practice management. However, only 15% conducted an annual diabetes check, 9% had a diabetic register, 6% a diabetic recall system and 8% used a diabetic health care checklist for monitoring their patients. The most commonly recorded processes of medical audit in the previous 12 months were: blood pressure (94%), duration of diabetes (72%), blood glucose (70%), diet (66%), body weight (56%), HBA1c (52%) and ophthalmoscopy (50%). The least commonly recorded processes of care were body mass index (5%), inspection of the feet (18%), enquiries about vaginitis or impotence (23%). The amount of exercise, alcohol and tobacco was recorded in only 34% of records. Hypoglycaemic drugs were used appropriately but the most commonly used drugs for treating hypertension in DM2 patients were thiazide diuretics and beta-blockers. Vocationally registered (VR) doctors had better records, higher process of care scores and more were willing to participate in the study than non-vocationally registered (NVR) doctors. However, there was no difference in metabolic control between patients from either group. The use of a Diabetic Health Care Checklist would improve diabetes care especially in the search for early complications and in the recording of HBA1c and other metabolic parameters. The drugs commonly used to control hypertension can have adverse effects on glucose and lipid metabolism and should be replaced with glucose and lipid neutral drugs.

Primary aging, secondary aging, and intelligence

The distinction between primary aging, representing innate maturational processes, and secondary aging, representing the effects of environment and disease (Busse, 1969), was used to develop a model for the assessment of factors that are associated with age-related individual differences in intelligence. Intelligence was measured by performance on a number of tests that measure cognitive abilities known to decline with age. In a hierarchical multiple regression analysis, primary aging and education but not health explained a significant portion of the variance in fluid intelligence. Chronological age had a residual effect over and above that of primary and secondary aging, indicating that there was remaining age-associated variance unaccounted for in the proposed model. The results suggest that the model of primary and secondary aging is a valid means of operationalizing chronological age.

Hearing impairment and hearing aid use in women over 65 years of age. Cross-sectional study of women in a large urban community

OBJECTIVES

(i) To describe the prevalence of self-reported hearing impairment and level of hearing aid use in women aged 65 years and over living in the community; (ii) to provide comparison findings from the National Health Survey and the Survey of Disability and Ageing undertaken by the Australian Bureau of Statistics.

DESIGN

Cross-sectional study of a large community population.

SETTING

Conducted as part of the Randwick Falls and Fractures Study, in Randwick a surburban area in eastern Sydney.

PARTICIPANTS

Four hundred and ninety-six women aged between 65 and 99 years (mean age, 74.6 years) took part in the study. The sample was representative of the population from which it was drawn.

RESULTS

We found a higher level of hearing difficulty than the levels reported in the Australian Bureau of Statistics surveys for women of comparative ages, which may reflect differences in the questions posed. The proportions with a hearing aid in the Randwick study and the Survey of Disability and Ageing were very similar (7.1% and 7.3% respectively). Of the one-third of the Randwick sample who reported a hearing difficulty, only half had been referred for audiometry and a quarter had been prescribed an aid. Only slightly more than a third of those who received an aid were regularly wearing it. Among the women with hearing difficulties, not using an aid was not associated with age, cognitive status or subjective health. There was a trend suggesting that those who did not use an aid had increased use of community support services. Women who had not received assistance with their hearing impairment had more difficulty shopping and relied more on family members.

CONCLUSION

Almost two-thirds of people prescribed a hearing aid were not wearing it regularly, denying themselves proven benefits in communication, social involvement and life satisfaction. The prescribing of these unused aids represents a huge waste of health resources. A program to increase hearing aid use by hearing impaired people may reduce the waste of health resources and the need for community support services. Such a program may greatly increase the life satisfaction for this very large group of disabled older people.