James R. McCartney

Assessment of cognitive deficit in geriatric patients: a study of physician behavior

A crucial factor in promoting a vigorous quality of life in the aging population is assessment and treatment of cognitive deficits. A very high percentage of delirium and at least 20% of dementia is eminently treatable. This study of patients over 65 years of age admitted to a university general hospital reveals that 79% of cognitive deficits were missed by the examining physicians. Furthermore, in 394 examinations of 165 patients, only four mental status examinations were recorded. A clear‐cut cognitive deficit on admission was predictive of later acute episodes of confusion. The global techniques of evaluation deserve remediable action by medical schools and hospital training programs if the medical care of the elderly is to be improved.

Sexuality and the Institutionalized Elderly

Sexuality is considered to be among the more disturbing sexual problems in skilled nursing facilities. Staff attitudes and beliefs often lead to discomfort in dealing with the continued sexual interests of patients. It is clear that if sexuality has been an important part of self‐image and of coping, then it remains important. Staff reaction to two cases is used to illustrate the need for programmatic interventions with staff, residents, and families.

The Effect of Cimetidine and Ranitidine on Cognitive Function in Postoperative Cardiac Surgical Patients

Objective: To compare the incidence of delirium in postoperative cardiac surgical patients treated with either cimetidine or ranitidine. Method: Cardiac surgery patients were randomized to receive either cimetidine or ranitidine postoperatively. Each patient underwent three Mini-Mental Status Examinations (MMSE) and the medical record was reviewed for pertinent past medical history, laboratory data, and evidence of delirium on three occasions: one day preoperatively (before H-2 blocker was given), in the early postoperative period (while receiving the H-2 blocker); usually two days postoperatively on the day of hospital discharge (several days after the H-2 blocker had been discontinued). Results: Overall, both groups in the early postoperative period showed a significant decrease in the MMSE score (27.11 ± 4.44 to 25.38 ± 2.87, mean ± SD; t = 5.16, p < .0005), which resolved by the time of hospital discharge. There was no significant difference between cimetidine and ranitidine. Both age and preoperative MMSE score were strongly associated with the development of delirium. Conclusions: We found no significant difference between cimetidines versus ranitidines effect upon cognitive functioning in the postoperative cardiac surgical patient. This was true even when controlling for age and length of stay.

Management of refusal of medical treatment.

As patients increasingly refuse medical and surgical treatment, the physicians response to this challenge to the healing-helping role is often extremely negative. Even though refusal may be felt by the patient as the only way to regain a measure of autonomy or control, such a response may have more to do with characteristic coping styles or interpersonal battles with the physician, staff, or family than with the treatment itself. Since management hinges on understanding the intrapersonal and interpersonal factors which contribute, it is essential to explore the meaning of the refusal. With reduction of the adversarial stance, the patient frequently regains enough sense of self to engage in a mutually cooperative effort. Even if the refusal stands, with understanding, the physician may be able to accept the patients choice, and extrusion from the system upon which the patient is still dependent is avoided.

Consultation-liaison psychiatry and the teaching of ethics

Medicine has undergone a technological explosion which presents physicians with an increased need to make difficult ethical decisions. This has been met by an equivalent development in American medical schools of efforts to teach the ethics of medical practice. The courses vary widely from school to school. It is recommended that a core curriculum of basic theory be taught in preclinical years, followed by case-centered teaching in clinical years and residency. Only with real cases can the influence of the doctor-patient relationship be appreciated. Teaching of ethics cannot be divorced from the clinical reality of the doctor-patient relationship. The emotional needs of both enter into all decisions. It is offered that consultation-liaison psychiatry, which addresses the needs of both, is an ideal focus for such teaching.

Postoperative hospital course of patients with history of severe psychiatric illness

The postoperative hospital course of 54 patients with a past history of psychiatric illness was studied through chart review. Both chronic schizophrenics and chronic depressives tolerated surgical procedures well, without any unusual difficulties or exacerbation of psychiatric illness. They represented no management problems. Patients with acute, severe upset in the preoperative period (regardless of diagnosis) presented most of the management problems postoperatively.