Jerry C. Johnson

Risk Factors for Dehydration Among Elderly Nursing Home Residents

Dehydration is the most common fluid and electrolyte disorder among the elderly, yet risk factors are not known. This study identifies risk factors for dehydration in acutely ill nursing home residents. All 339 elderly residents of two nursing homes who developed an acute illness requiring hospitalization during 1984 were included in the study. The 173 patients having a serum Na < 150 mg/dL and blood urea nitrogen to creatinine ratio (BUN:Cre) < 20 were designated controls; 91 patients having a serum Na > 150 mg/dL or a serum BUN:Cre > 25 were designated cases. Odds ratios (OR) and confidence intervals were calculated for age, sex, chronic conditions, acute illnesses, medications, functional status measures, and season. Acutely ill dehydrated patients were female (OR, 3.3); over 85 years old (OR, 2.2); had more than four chronic conditions (OR, 4.0); took more than four medications (OR, 2.8); and were bedridden (OR, 2.9). Among the most severely dehydrated (serum Na > 150 mg/dL and BUN:Cre > 25), the odds ratios for the above factors were strengthened and other factors, such as inability to feed oneself and type of acute diagnosis, emerged as risk factors. Among the variables unrelated to functional status, laxatives (OR, 3.2) and chronic infections (OR, 1.8) were risk factors. We conclude that a group at high risk for dehydration can be defined and that they are better characterized by the number of chronic diseases and debilitated functional status than by acute disease processes.

The burden of depression in prostate cancer

We sought to analyze the prevalence and incremental burden of depression among elderly with prostate cancer.

Survival of Hospitalized Elderly Patients With Delirium: A Prospective Study

The authors tested the relationship between clinically diagnosed delirium during hospitalization and increased mortality after accounting for pre-hospital measures of global cognition, physical functioning, and medical comorbidity. Patients (N=102), 53 of which were hospitalized during the course of a year, received the Mini-Mental State Exam, Physical Self-Maintenance Scale, Cumulative Illness Rating Scale, and 15-item Geriatric Depression Scale. Mortality rates were determined at discharge and after 3 years. Patients who developed delirium did not differ on pre-hospitalization levels of depression, global cognitive performance, physical functioning, or medical comorbidity. Three-year mortality in the hospitalized subjects was 75% for delirium patients vs. 51% for control patients (risk ratio=2.24). Delirium occurring during hospitalization places elderly subjects at long-term risk of mortality. This effect is not accounted for by earlier measures of cognitive, functional, or health status.

Nonspecific Presentation of Pneumonia in Hospitalized Older People: Age Effect or Dementia?

OBJECTIVES: Older adults, when presenting with pneumonia, are often thought to present with nonspecific symptoms instead of more suggestive symptom(s). However, studies designed to determine whether age is associated with nonspecific presentations have yielded contradictory results. Many studies have not distinguished between the effects of preexisting cognitive impairment that results from dementia and the effects of age. The aim of this study is to determine whether there are significant differences in the presentation of pneumonia in demented versus nondemented patients across two age groups. We hypothesized that the nonspecific presentation of pneumonia in older people is due to dementia rather than to chronological age.

Prospective versus retrospective methods of identifying patients with delirium.

To determine if DSM‐III criteria or clinical or discharge diagnoses, reviewed retrospectively, are as accurate an indicator of the presence of delirium as prospective evaluation by a psychiatrist.

Ethnic variation in return to baseline values of patient-reported outcomes in older prostate cancer patients.

Ethnic variation in patient‐reported outcomes such as health‐related quality of life (HRQoL) and satisfaction with care are understudied areas in the management of elderly prostate cancer (PCa) patients.

Differential diagnosis of dementia, delirium and depression. Implications for drug therapy.

SummaryDementia, delirium and depression are the 3 most prevalent mental disorders in the elderly. While dementia and depression are prevalent in the community, hospitals and nursing homes, delirium is seen most often in acute care hospitals. Much of the management of these syndromes is undertaken by primary care physicians rather than psychiatrists. Therefore, it is imperative that generalist physicians be adept at recognising, evaluating and managing patients with these syndromes.Because no diagnostic tests are pathognomonic of these syndromes, the differential diagnosis hinges on a careful clinical evaluation. The first step is to recognise which of the syndromes is present. Dementia is defined by a chronic loss of intellectual or cognitive function of sufficient severity to interfere with social or occupational function. Delirium is an acute disturbance of consciousness marked by an attention deficit and a change in cognitive function. Depression is an affective disorder evidenced by a dysphoric mood, but the most pervasive symptom is a loss of ability to enjoy usual activities. It is important to recognise that these syndromes are not mutually exclusive, as dementia frequently coexists with delirium and depression. Furthermore, physical diagnoses, such as chronic obstructive lung disease, congestive heart failure, stroke and endocrine disorders, are frequently associated with depressive symptoms. Given this, a comprehensive evaluation is mandatory.Laboratory tests are necessary to exclude concurrent metabolic, endocrine and infectious disorders, and drug effects. Imaging studies should be obtained selectively in patients with signs and symptoms, such as focal neurological findings and gait disturbances, which are suggestive of structural lesions: stroke, subdural haematoma, normal pressure hydrocephalus and brain tumours. Appropriate management involving pharmacological and nonpharmacological measures will result in significant improvement in most patients with these syndromes. Potentially offending drugs should be discontinued. In delirious patients the underlying illness must be treated concomitantly with the use of psychotropics, if necessary.Although no current medications have been shown to have a significant effect on the functional status of patients with the 2 most common causes of dementia, Alzheimer’s disease and multi-infarct dementia, the management of concomitant illness in these patients may result in improved function for as long as a year. Tacrine, an anticholinesterase inhibitor, improves cognitive function slightly in selected patients with Alzheimer’s disease over short periods. Finally, the treatment of depression with medications or electroconvulsive therapy (ECT) results in significant reductions in mortality and morbidity.

Quality improvement in neurology Dementia management quality measures

ACOVE= : Assessing Care of Vulnerable Elders; DWG= : Dementia Measures Work Group; EHR= : electronic health record; ICD-9 = : International Classification of Diseases , ninth revision; MU= : Meaningful Use; PCPI= : Physician Consortium for Performance Improvement; PQRS= :

Identifying and Recognizing Delirium

Clinicians fequently under-recognize delirium. Physicians and nurses can be taught to recognize delirium by focusing on each of the components of the criteria for delirium. Teachers of physicians and nurses should emphasize the ability to recognize acuteness of onset, fluctuation of course, and attention deficits. Attention deficits in the clinical setting can be recognized by digit span testing, spelling words backwards, or assessing accessibility during the clinical interview. Attention can be scored by assigning a score from 0–10, or ranking as mild, moderate or severe, the patients ability to engage in the medical interview.

Extending the Pipeline for Minority Physicians: A Comprehensive Program for Minority Faculty Development.

Medical schools must become more successful in training minority faculty. Minority faculty development programs at schools of medicine must involve trainees from the undergraduate years (if not before) through junior faculty and must involve MD and combine-degree (MD-PhD) students. The authors describe the comprehensive minority faculty development program at the University of Pennsylvania School of Medicine, which involves minority undergraduates, medical students, residents, fellows, and faculty. This program provides the administrative staff and research methodologists to assist trainees at all levels across all departments in the school of medicine. The principal student recruitment program is the undergraduate premedicine enrichment program. The medical student component provides general counseling, research development, and activities to enhance performance in the clinical courses. The components for advanced trainees (residents, fellows, and postdoctoral trainees) and faculty consist of training in research methods, mentoring, teaching skills, and scientific writing skills. Through this program, the University of Pennsylvania School of Medicine has increased the number of under-represented minority faculty by 32% since 1993-94 and created an environment conducive to the professional growth and development of minority faculty.