Gisele Wolf-Klein

Screening for Alzheimer's Disease by Clock Drawing

The fear of Alzheimers disease for both patients and families is growing along with the increasing evidence of the disease itself. This study (N = 312) of the validity of the clock drawing test in screening patients with probable Alzheimers disease was conducted in an active outpatient geriatric clinic. Clock drawings by patients with normal mental status or depression were essentially normal. Alzheimers patients were unable to complete a normal clock and demonstrated five characteristically abnormal patterns. As a test for Alzheimers disease, clock drawing had a sensitivity of 86.7% and a specificity of 92.7%. There was correct identification in 97.2% of normals. These findings indicate that the clock drawing test, an easily administered, low cost screening tool, can be useful to health care professionals in characterizing cognitive loss in a general geriatric clinic population.

Are Alzheimer Patients Healthier

At an active outpatient geriatric program the gerontological team observed that Alzheimer patients appear to have fewer physical ailments than other elderly patients. To test this hypothesis, we reviewed a sample of 348 clinic patients. One hundred forty‐three had a normal mental status; 75 had Alzheimers disease as defined by DSM‐III criteria; 139 had an abnormal mental status attributed to other etilogies. The number of diagnoses was compiled in each of the three groups. The average number of diagnoses in the nondemented group was 5.0 in males, 5.4 in females. In the non‐Alzheimer abnormal mental status group, the average number was 5.5 in males, 4.6 in females. In contrast, the number of diagnoses in the Alzheimer group was 2.9 in males and 2.8 in females (P < 0.0001). Cardiovascular diseases, hypertension, and cerebrovascular accidents were less frequent in the Alzheimer population. This study suggests that Alzheimer patients are physically healthier than non‐Alzheimer elderly patients.

Determination of Normal Ear Temperature with an Infrared Emission Detection Thermometer

STUDY OBJECTIVE To determine normal body temperature with an infrared emission detection ear thermometer. DESIGN Cross-sectional convenience sample. SETTING Four acute and long-term health care facilities. PARTICIPANTS Subjects who denied recent potentially febrile illness and ingestion of medications affecting normal body temperature. RESULTS Two thousand four hundred forty-seven subjects aged 12 hours to 103 years were enrolled. Ear temperatures were normally distributed for each of eight age groups. There were differences in mean temperature among different age groups (P < .001, by ANOVA) and a striking cutoff at adolescence; the mean temperature for children aged 3 days to 10 years was 36.78 +/- 0.47 degrees C, as compared to 36.51 +/- 0.46 degrees C for subjects 11 years and older (P < .001, by t test). Temperatures were higher in female subjects and showed the characteristic diurnal variation of normal body temperature in five subjects studied longitudinally. The reproducibility of the ear thermometer was better than that of a commonly used electronic thermometer at the oral and axillary sites. CONCLUSION The infrared emission detection ear thermometer is an accurate means of assessing normal body temperature without using corrective offsets to estimate temperature at other body sites. On the basis of these data, the 95th percentile for infrared emission detection temperature in children younger than 11 years old was 37.6 degrees C. The 99th percentile was 37.9 degrees C for children younger than 11 years old and 37.6 degrees C for people 11 years or older. Because only 1% of normal people have an infrared emission detection temperature higher than these values, these may represent appropriate cutoffs for fever screening using this device.

Factors influencing older adults to complete advance directives.

OBJECTIVE The purpose of this study was to determine the factors which influence advance directive (AD) completion among older adults. METHOD Direct interviews of hospitalized and community-dwelling cognitively intact patients > 65 years of age were conducted in three tertiary teaching settings in New York. Analysis of AD completion focused on its correlation with demographics, personal beliefs, knowledge, attitudes, and exposure to educational media initiatives. We identified five variables with loadings of at least 0.30 in absolute value, along with five demographic variables (significant in the univariate analyses) for multiple logistic regression. The backward elimination method was used to select the final set of jointly significant predictor variables. RESULTS Of the 200 subjects consenting to an interview, 125 subjects (63%) had completed ADs. In comparing groups with and without ADs, gender (p < 0.0002), age (p < 0.0161), race (p < 0.0001), education (p < 0.0039), and religion (p < 0.0104) were significantly associated with having an AD. Factors predicting AD completion are: thinking an AD will help in the relief of suffering at the end of life, (OR 76.3, p < 0.0001), being asked to complete ADs/ or receiving explanation about ADs (OR 55.2, p < 0.0001), having undergone major surgery (OR 6.3, p < 0.0017), female gender (OR 11.1, p < 0.0001) and increasing age (76-85 vs. 59-75: OR 3.4, p < 0.0543; < 85 vs. 59-75: OR 6.3, p < 0.0263). SIGNIFICANCE OF RESULTS This study suggests that among older adults, the probability of completing ADs is related to personal requests by health care providers, educational level, and exposure to advance care planning media campaigns.

Weight Loss in Alzheimer's Disease: An International Review of the Literature

Alzheimers disease affects an estimated 2 million elderly in the U.S. and challenges primary care physicians to assist caregivers in dealing with the daily management of these patients. To support the clinical observation of weight loss in Alzheimer patients despite adequate food intake, we reviewed the existing literature. To date, eight international studies have focused on nutrition in Alzheimers disease and all have found weight loss. It is not clear whether this weight loss is a component of or a consequence of the disease. These findings suggest systemic, metabolic alterations in Alzheimers disease. They require further investigation as to their nature and as to their appropriate recognition and management to retard the deteriorating effects of chronic weight loss and malnutrition. Finally, some reports lead to speculation that nutritional strategies may improve cognitive function.

Nutritional patterns and weight change in Alzheimer patients.

A nutritional study of 100 patients enrolled in an active geriatric outpatient teaching program was conducted to document the clinical impression of weight loss in Alzheimers disease. All new patients were asked to complete a questionnaire on nutrition. Patients were evaluated by a geriatrician, then categorized using DSM-III and NINCDS-ADRDA criteria. There were 34 Alzheimer patients and 60 nondemented patients with an average weight of 56.2 kgs and 66.1 kgs, respectively (p less than .002). Of the Alzheimer group, 44% reported weight loss in the past five years compared with 37% of the nondemented group, despite a concomitant increase in food intake in 35% versus 7%, respectively. On a one-year follow-up, 92% of Alzheimer patients lost weight, whereas 57% of the nondemented patients actually gained weight. The increase in reported food intake, with a significant concomitant weight loss, raises some challenging questions as to the existence of a hypermetabolic state in Alzheimers disease.

Hypouricemia, abnormal renal tubular urate transport, and plasma natriuretic factor(s) in patients with Alzheimer's disease

To study tubular urate transport in Alzheimers disease (AD) and measure sodium and lithium transport rates in rats exposed to AD plasma.

Diagnostic Value of Repeated Enzyme Immunoassays in Clostridium difficile Infection

OBJECTIVES:There has been a significant increase in the prevalence, severity, and mortality of Clostridium difficile infection (CDI), with an estimated three million new cases per year in the United States. Yet diagnosing CDI remains problematic. The most commonly used test is stool enzyme immunoassay (EIA) detecting toxin A and/or B, but there are no clear guidelines specifying the optimal number of tests to be ordered in the diagnostic workup, although multiple tests are frequently ordered. Thus, we designed a study with the primary objective of evaluating the diagnostic utility of repeat second and third tests of stool EIA detecting both toxins A and B (EIA (A&B)) in cases with negative initial samples, and sought to describe the physicians’ patterns of ordering this test in the workup of suspected CDI.METHODS:A retrospective study was carried out using a database of all stool EIA (A&B) tests ordered for a presumptive diagnosis of CDI. All patients were adults admitted to a major teaching hospital over a three-and-a-half-year period (tests completed within 5 days of ordering the first test were grouped into a single episode, and only the first three samples per episode were analyzed). Age, gender, and results of stool EIA were tabulated. In addition, physicians’ ordering patterns and proportion of positive stools relative to the number of tests ordered were also analyzed. A single positive EIA result was interpreted as evidence for the clinical presence of CDI.RESULTS:A total of 3,712 patients contributed to 5,865 separate diarrhea episodes (total stool EIA (A&B)=9,178), and 1,165 (19.9%) of these episodes were positive for CDI. Of the positive patients, 73.2% were over the age of 65 years and 54.2% of them were females. The most frequent ordering pattern for presumptive CDI was a single stool test (60.1%), followed by two more tests (23.2%). Three tests were still ordered in 16.6% of the cases. Of the 1,165 positive cases, 1,046 (89.8%) were diagnosed in the very first test, 95 (8.2%) in the second, and only 24 (2.0%) in the third test. In 1,934 instances, a second test was ordered after an initial negative result, of which 95 (4.91%) became positive. In 793 episodes, a third test was ordered after two negative samples, of which only 24 (3.03%) became positive.CONCLUSIONS:This study highlights the low diagnostic yield of repeat stool EIA (A&B) testing. Findings strongly support the utility of limiting the workup of suspected CDI to a single stool test with only one repeat test in cases of high clinical suspicion, and avoiding the routine ordering of multiple stool samples. As Clostridium difficile is becoming an endemic health-care problem resulting in major financial burdens for the US health-care system, clear guidelines specifying the optimal number of stool EIA (A&B) tests to be ordered in the diagnostic workup of suspected CDI must be established to assist physicians in the practice of evidence-based medicine.

Hand hygiene in long-term care facilities: a multicenter study of knowledge, attitudes, practices, and barriers.

An anonymous survey of 1143 employees in 17 nursing facilities assessed knowledge of, attitudes about, self-perceived compliance with, and barriers to implementing the 2002 Centers for Disease Control and Prevention hand hygiene guidelines. Overall, employees reported positive attitudes toward the guidelines but differed with regard to knowledge, compliance, and perceived barriers. These findings provide guidance for practice improvement programs in long-term care settings.

Conceptualizing Alzheimer's Disease as a Terminal Medical Illness

Alzheimers disease is a common illness of the elderly population, with an estimated prevalence of 4.5 million people in the United States and 24.3 million worldwide. Despite current pharmaceutic advances in delaying disease progression, there is no cure. This article reviews the evidence for conceptualizing Alzheimers disease as a terminal medical illness. Discussed are principles of palliative care as applied to the patient with Alzheimers disease and the patients family.