Dulce M. Cruz-Oliver

THE RAPID COGNITIVE SCREEN (RCS): A POINT-OF-CARE SCREENING FOR DEMENTIA AND MILD COGNITIVE IMPAIRMENT

ObjectivesThere is a need for a rapid screening test for mild cognitive impairment (MCI) and dementia to be used by primary care physicians. The Rapid Cognitive Screen (RCS) is a brief screening tool (< 3 min) for cognitive dysfunction. RCS includes 3-items from the Veterans Affairs Saint Louis University Mental Status (SLUMS) exam: recall, clock drawing, and insight. Study objectives were to: 1) examine the RCS sensitivity and specificity for MCI and dementia, 2) evaluate the RCS predictive validity for nursing home placement and mortality, and 3) compare the RCS to the clock drawing test (CDT) plus recall.MethodsPatients were recruited from the St. Louis, MO Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Medical Center (VAMC) hospitals (study 1) or the Saint Louis University Geriatric Medicine and Psychiatry outpatient clinics (study 2). Study 1 participants (N=702; ages 65–92) completed cognitive evaluations and 76% (n=533/706) were followed up to 7.5 years for nursing home placement and mortality. Receiver operator characteristic (ROC) curves were computed to determine sensitivity and specificity for MCI (n=180) and dementia (n=82). Logistic regressions were computed for nursing home placement (n=31) and mortality (n=176). Study 2 participants (N=168; ages 60–90) completed the RCS and SLUMS exam. ROC curves were computed to determine sensitivity and specificity for MCI (n=61) and dementia (n=74).ResultsRCS predicted dementia and MCI in study 1 with optimal cutoff scores of ≤ 5 for dementia (sensitivity=0.89, specificity=0.94) and ≤ 7 for MCI (sensitivity=0.87, specificity=0.70). The CDT plus recall predicted dementia and MCI in study 1 with optimal cutoff scores of ≤ 2 for dementia (sensitivity=0.87, specificity=0.85) and ≤ 3 for MCI (sensitivity=0.62, specificity=0.62). Higher RCS scores were protective against nursing home placement and mortality. The RCS predicted dementia and MCI in study 2.ConclusionsThe 3-item RCS exhibits good sensitivity and specificity for the detection of MCI and dementia, and higher cognitive function on the RCS is protective against nursing home placement and mortality. The RCS may be a useful screening instrument for the detection of cognitive dysfunction in the primary care setting.

Veterans affairs Saint Louis university mental status examination compared with the Montreal cognitive assessment and the short test of mental status

To compare the ability of the Veterans Affairs Saint Louis University Mental Status (SLUMS) examination to detect mild cognitive impairment (MCI) and dementia according to the Clinical Dementia Rating Scale (CDR) with that of two other well‐known screening instruments, the Montreal Cognitive Assessment (MoCA) and the Short Test of Mental Status (STMS).

The veterans affairs Saint Louis University mental status exam (slums exam) and the mini-mental status exam as predictors of mortality and institutionalization

ObjectiveTo evaluate predictive validity of cognitive dysfunction of the Saint Louis University Mental Status (SLUMS) exam or Mini-Mental State Exam (MMSE) for institutionalization and mortality after 7.5-years.DesignLongitudinal study.SettingGeriatric Research, Education and Clinical Center Veterans Affairs Hospital St. Louis, MO.ParticipantsPatients (N=705) were screened for cognitive dysfunction in 2003 using the SLUMS exam and MMSE, and mortality and institutionalization up to 7.5-years later were evaluated as outcome measures.MeasurementThe associations between outcome measures and MMSE and SLUMS exam total scores, and cognitive status were examined using Kaplan-Meier curves and Cox proportional-hazards regression.ResultsFive hundred thirty-three charts were reviewed, 176/533(33%) patients had died and 31/526 (6%) were institutionalized during 7.5-year follow-up period. All subjects were male with a mean age of 75 years and most had high school education or greater (71%). MMSE dementia, SLUMS dementia (ps<.001) and MCI (p<.05) groups had significantly lower survival rates than normal cognition group in the Kaplan-Meier curves. Scores classified as dementia on SLUMS (HR=2.4, 95% CI 1.6–3.7; p <.001) or MMSE (HR=2.3, 95% CI 1.5–3.6; p <.001) both predicted mortality and, also, institutionalization (SLUMS: HR=3.5, 95% CI 1.3–9.1; p <.01; MMSE: HR=3.8, 95% CI 1.6–9.0; p <.001) after adjustment for covariates. Unadjusted SLUMS exam MCI predicted morality (HR=1.5, 95% CI 1.1–2.2; p <.019) but not institutionalization.ConclusionThe SLUMS exam and MMSE both predict mortality and institutionalization for male patients screened as positive for dementia.

What Evidence is Available on End-of-life (EOL) Care and Latino Elders? A Literature Review

Background: Low-income and minority persons, such as Latinos, encounter substantial barriers in accessing effective end-of-life (EOL) care. This study intends to review current evidence on how to deliver EOL care to Latino elders. Methods: Literature search in PubMed and Ovid Web sites of articles indexed in Medline (1948-2011), Cochrane (2005-2011), Embase, and PsychInfo (1967-2011) databases. Articles were included if they contained (1) study participants’ race/ethnicity, (2) adults or population older than 60 years, and (3) information related to EOL care. Results: A total of 64 abstracts were reviewed, and 38 articles met the inclusion criteria. After reviewing the quality of evidence, 4 themes were identified and summarized: EOL preferences, hospice, Latino culture, and caregiving. Conclusion: Latino elders have traditional acculturation practices, face EOL decisions with family support, and, if educated, are receptive toward hospice and caregiver support.

Early Detection of Cognitive Impairment: Do Screening Tests Help?

Dulce M. Cruz-Oliver, MD, and John E. Morley, MB, BCh Dementia is defined as an acquired loss of memory that is substantial enough to interfere with everyday functioning. Although many types of dementia exist, most patients with dementia have Alzheimer’s disease (AD), vascular dementia, or Lewy body dementia. Age is the greatest risk factor for developing dementia; its incidence and prevalence increase dramatically in persons older than 65 years. Specifically, AD affects approximately 25% to 30% of individuals older than65yearsand doublesin incidenceforevery 5years thereafter. As a result, the prevalence of AD approaches 50% among persons older than 85 years. 1 Genetic risk factors have also been related to AD. The most prevalent is the apolipoprotein E (APOE) e4 allele. Caselli et al 2 explored the age-related trajectories of memory loss in APOE carriers and noncarriers and found that homozygous carriers have earlier onset of memory impairment than noncarriers in the absence of mild cognitive impairment (MCI) or AD. Patients with AD have an average life expectancy of 8 to 10 years after symptom onset and asthe diseaseprogresses aloss inactivities of daily living ensues. This entails caregiver burden and with time it becomes so overwhelming that it is a major contributing factor to the decision to institutionalize a patient with dementia. One approach to this highly prevalent disease is its early detection for early treatment and prevention. For this reason recent research has focused on detection of early dementia and the transitional stage of cognitive impairment between normal aging and early dementia, so-called mild cognitive impairment. Figure 1 gives a simple approach to the diagnosis of dementia and MCI. 3 This article intends to point out the ability of current screening tools to detect MCI and dementia, and to summarize 3 aspects of these conditions: prognosis, diagnosis, and treatment, in the community as well as nursing home settings. The term ‘‘mild cognitive impairment’’ (MCI) was first introduced in the late 1980s by the New York University group 4 and it refers to the clinical state of individuals who are memory impaired but otherwise functioning well and do not meet

Cognitive Stimulation Therapy

Cognitive stimulation therapy (CST) is an organized group therapy program that was developed for persons with cognitive impairment (www.cstdementia.com). It uses a structured approach to stimulate and engage persons with memory impairment. It uses mental stimulation, reminiscence, orientation, and a focus on opinions rather than fact to enhance a person’s function. Previous studies have suggested that reminiscence therapy has a positive effect on quality of

Education Intervention “Caregivers Like Me” for Latino Family Caregivers Improved Attitudes Toward Professional Assistance at End-of-life Care

Objective: This study explores the ability of a culturally sensitive and case-based education intervention, Caregivers Like Me, to improve knowledge and attitudes regarding end-of-life (EOL) resources among Latino caregivers. Methods: A multicentered, cross-sectional study of Latino communities from different geographical regions and cultural backgrounds. An educational intervention was administered to family caregivers of Latino elders using a case-based video “telenovela” and pretest–posttest questionnaires. Results: Participants (N = 145) were mostly females (79%) with mean age of 56 ± 15 years. They reported active learning from intervention (91%) and high satisfaction (92%) with educational experience. Both caregiver stress self-awareness and willingness to accept professional help improved significantly from pretest to posttest. Conclusion: A culturally sensitive educational intervention increased Latino caregivers’ self-awareness about caregiver stress and the need to consider professional assistance for EOL care.

End-of-Life Care in the Nursing Home

By virtue of its structure, Western medicine is characterized by its cure-oriented approach to the patient. We pretend to master death and the fear of death, according to Dr Elizabeth Kübler-Ross. We are uncomfortable in situations when the patient’s prognosis is poor, because as health care providers, we are instilled with the idea that the ultimate goal in patient care is curing the patient. Thus, the fear of failure looms when aggressive treatment is no longer possible and many providers are reluctant to be straightforward with families in discussing end-of-life (EOL) care options. Unfortunately, this pandemic attitude of denial and avoidance has the unintended consequence of alienating both the dying and the aged and is a true disservice to all patients. Additionally, the current approach to EOL care often fails to accept the inevitable notion that just as there is a time for living, there is also a time for dying. With the advances in medical technology, one of the real challenges of modern medicine is accepting that dying is part of life’s journey for all individuals and that death does not represent a failure of the health care system or health care providers. While working as a nurse and social worker with cancer patients, Cicely Saunders became aware of the extremely inadequate care provided for dying patients in England. She felt that the dying patient was not approached in a holisticmanner and that the spiritual and emotional aspects of the dying process were most often neglected. After becoming a physician, Dr Saunders founded the first hospice in London in 1967 and spent most of her life researching pain management. Her philosophy and tireless work on behalf of the dying ultimately led to the creation of themedical specialty of palliative care and has undoubtedly resulted in making death a more humane process for countless numbers of patients. No doubt this movement has beenmarked by the increasing importance of nurses in the role of direct caregivers of dying patients. One quarter of American elders die while institutionalized and one third of those die within 12 months of admission to a facility. This certainly underscores the notion that EOL care in nursing homes (NHs) has received special attention

Hospice/Palliative Care: Concepts of Disease and Dying

Population across the globe is not only aging but also becoming ethnically diverse. This is critically important in providing patient–centered end of life (EOL) care. This recognized diversity in the lived experience of ethnic older adults requires that the patient be individually assessed for their language of preference, need for interpreter use, health beliefs, cultural values, knowledge of disease process and hospice care during clinical encounter. Literature about ethnic older adults EOL is limited because it is based on observational research of low quality, on data extrapolated from younger generation and each ethnic group is heterogeneous in itself. Healthcare disparities in EOL exist for various reasons (i.e. geography, supply, and EOL conversation) but race and ethnicity reporting differ among research studies and very seldom ethnicity solely explain EOL care disparity. The following chapter intends to describe the delivery of EOL care, cultural background influences in death and disease concepts, EOL preferences and hospice use among ethnically diverse elders. A list of suggestions is provided to enhance EOL care by improving research, education, policy and communication with ethnic older adults with advance illness and their family caregivers.

End-of-life care in low-and middle-income countries

End-of-life care in lowand middle-income countries Dulce M Cruz-Oliver, Milta O Little, Jean Woo & John E Morley a Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, Saint Louis, MO, 63104, United States of America. b Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China. Correspondence to Dulce M Cruz-Oliver (email: dcruzoli@slu.edu). (Submitted: 14 September 2016 – Accepted: 6 October 2016 – Published online: 26 September 2017) Health-care providers are recognizing the importance of palliative and end-of-life care as a treatment option for seriously ill patients. Palliative care is an approach to improve the quality of life of patients and their families facing problems associated with life-threatening illness, through the prevention and relief of suffering, by means of early identification, assessment and treatment of pain and other distresses. 1 Palliative care begins at the start of a serious illness and is given alongside treatments designed to combat the disease. End-of-life care is a type of palliative care for people in the final months of life and is considered when the person’s condition deteriorates and active treatment does not control the disease. Palliative and end-of-life care helps those with advanced, progressive, incurable and serious illness to live as well as possible until they die. 2