Jules Rosen

Financial Exploitation and Psychological Mistreatment Among Older Adults: Differences Between African Americans and Non-African Americans in a Population-Based Survey

PURPOSE to examine racial differences in (a) the prevalence of financial exploitation and psychological mistreatment since turning 60 and in the past 6 months and (b) the experience-perpetrator, frequency, and degree of upset-of psychological mistreatment in the past 6 months. DESIGN AND METHODS random digit dial telephone recruitment and population-based survey (telephone and in-person) of 903 adults aged 60 years and older in Allegheny County (Pittsburgh), Pennsylvania (693 non-African American and 210 African American). Covariates included sex, age, education, marital status, household composition, cognitive function, instrumental activities of daily living/activities of daily living difficulties, and depression symptoms. RESULTS prevalence rates were significantly higher for African Americans than for non-African Americans for financial exploitation since turning 60 (23.0% vs. 8.4%) and in the past 6 months (12.9% vs. 2.4%) and for psychological mistreatment since turning 60 (24.4% vs. 13.2%) and in the past 6 months (16.1% vs. 7.2%). These differences remained once all covariates were controlled in logistic regression models. There were also racial differences in the experience of psychological mistreatment in the past 6 months. Risk for clinical depression was also a consistent predictor of financial exploitation and psychological mistreatment. IMPLICATIONS although the results will need to be replicated in national surveys, the study suggests that racial differences in elder mistreatment are a potentially serious issue deserving of continued attention from researchers, health providers, and social service professionals.

Emergence of psychosis and depression in the longitudinal evaluation of Alzheimer's disease

Prospective psychiatric evaluations were performed as part of a longitudinal study of 32 demented patients who met criteria for the histopathological diagnosis of Alzheimers disease at the time of death. Psychosis and major depressive disorder emerged in 15 (47%) and 7 (22%) patients, respectively, none of whom had a history of either behavioral disorder prior to the onset of dementia. The prevalence of psychosis increased with increasing dementia severity, was associated with more rapid cognitive decline, and once present was often persistent. In this regard, the emergence of psychosis in the context of Alzheimers disease appears to be a poor prognostic sign. In contrast to its relationship to cognitive impairment, psychosis was not associated with an increased mortality rate.

Determinants of staff job satisfaction of caregivers in two nursing homes in Pennsylvania

BackgroundJob satisfaction is important for nursing home staff and nursing home management, as it is associated with absenteeism, turnover, and quality of care. However, we know little about factors associated with job satisfaction and dissatisfaction for nursing home workers.MethodsIn this investigation, we use data from 251 caregivers (i.e., Registered Nurses, Licensed Practical Nurses, and Nurse Aides) to examine: job satisfaction scores of these caregivers and what characteristics of these caregivers are associated with job satisfaction. The data were collected from two nursing homes over a two and a half year period with five waves of data collection at six-month intervals. The Job Description Index was used to collect job satisfaction data.ResultsWe find that, overall nursing home caregivers are satisfied with the work and coworkers, but are less satisfied with promotional opportunities, superiors, and compensation. From exploratory factor analysis three domains represented the data, pay, management, and work. Nurse aides appear particularly sensitive to the work domain. Of significance, we also find that caregivers who perceived the quality of care to be high have higher job satisfaction on all three domains than those who do not.ConclusionThese results may be important in guiding caregiver retention initiatives in nursing homes. The finding for quality may be especially important, and indicates that nursing homes that improve their quality may have a positive impact on job satisfaction of staff, and thereby reduce their turnover rates.

The 5-HTTPR Polymorphism Confers Liability to a Combined Phenotype of Psychotic and Aggressive Behavior in Alzheimer Disease

BACKGROUND Psychotic symptoms in subjects with Alzheimer disease (AD+psychosis, AD+P) are a marker for a distinct phenotype characterized by more rapid cognitive and functional decline and a liability to aggressive behaviors. We recently found that AD subjects homozygous for long alleles (l) of an insertion/deletion polymorphism in the promoter region of the serotonin transporter (5-HTTPR) had elevated rates of aggressive behavior. OBJECTIVE To examine whether the 5-HTTPR ll genotype confers an increased risk of AD+P, and of the combined AD+P/aggressive phenotype. METHODS The 5-HTTPR genotype was determined in 332 subjects diagnosed with possible or probable AD. All subjects received structured psychiatric assessments and were categorized with regard to their history of aggressive behaviors and psychotic symptoms. RESULTS Consistent with other reports, AD+P was associated with a significant increased risk for aggressive behavior. AD+P and aggression were both significantly associated with 5-HTTPR ll genotype and with an increased l allele frequency. Subjects with the combined behavioral phenotype (AD+P and aggressive behavior) had the highest rate of ll genotype and highest l allele frequency. CONCLUSION The 5-HTTPR l allele appears to confer risk for the combined AD+P/aggressive phenotype. Confirmation of this association in a similar behaviorally well-characterized independent sample is needed.

Association of the APOE ε4 allele with clinical subtypes of late life depression

The APOE genotypes of 45 elderly inpatients with major depression were determined to investigate the relationship of this disorder to irreversible dementia in late life. We specifically tested the hypothesis that the frequency of the APOE e 4 allele is elevated in depressed elders with cognitive impairment or psychotic features, subtypes that have been reported to be at increased risk of developing Alzheimers disease (AD). The frequency of e 4 allele was not elevated in the overall group of 45 inpatients and, contrary to our expectation, was not associated with cognitive impairment in this group. In contrast, the e 4 allele frequency for the patients with psychotic features was nearly four times that for the patients without psychotic features and nearly double that of elderly controls. These data suggest that elderly depressed inpatients with cognitive impairment are at risk for developing AD by an e 4-independent pathway, while those with psychotic features are at risk for developing AD by an e 4-dependent pathway. These findings suggest that subtypes of idiopathic major depression in late life may serve as landmarks that distinguish separable pathogenetic pathways to AD.

A Prospective Naturalistic Study of Electroconvulsive Therapy in Late-Life Depression

We performed a prospective, naturalistic study using standardized clinical rating scales to characterize the effect of electroconvulsive therapy (ECT) on mood, cognition, and medical status in late-life depression. Over a 16-month period, 40 patients aged 60 years and over who fulfilled DSM-III criteria for a major depressive episode received a total of 42 ECT courses. Three patients (7%) developed significant medical complications: one had a syncopal episode due to arrhythmia, and two had symptomatic vertebral compression fractures. Confusion was noted during 13 courses (31%) and persisted at discharge in four (10%). More than half the patients were either psychotic or demented on admission, and all but three had been either unresponsive or intolerant to pharmacotherapy. All patients experienced a decrease in their depressive symptoms and more than two thirds were in complete or partial remission at discharge. Patients with psychotic depression experienced a greater improvement than patients with nonpsychotic depression, and patients with organic mental disorders experienced the same improvement as other patients. This study confirms that ECT is a safe and effective treatment of depression in late life. (J Geriatr Psychiatry Neurol 1991; 4:3-13).

Stayers, Leavers, and Switchers Among Certified Nursing Assistants in Nursing Homes: A Longitudinal Investigation of Turnover Intent, Staff Retention, and Turnover

PURPOSE Studies of certified nursing assistant (CNA) turnover in nursing homes are typically cross-sectional and include full-time and part-time workers. We conducted a longitudinal study to evaluate the job factors and work attitudes associated with just full-time staying or leaving. For those who did not stay, we assessed reasons for leaving and satisfaction following job transition. DESIGN AND METHODS A random sample of CNAs identified through the Pennsylvania Department of Healths CNA registry, working ≥ 30 hr weekly in a nursing facility was surveyed by telephone at baseline and 1 year later. RESULTS Of the 620 responding to both surveys, 532 (85.8%) remained (stayers), 52 (8.4%) switched to another facility (switchers), and 36 (5.8%) left the industry (leavers). At baseline, switchers reported higher turnover intentions and fewer benefits compared with stayers and left for new opportunities. Leavers had lower job satisfaction and emotional well-being and left for health reasons. Turnover intentions were predicted by low job satisfaction and low emotional well-being. Actual turnover was predicted only by turnover intentions and by the absence of health insurance. Pay was not a predictor of turnover intent or turnover. IMPLICATIONS There are two distinct groups of CNAs contributing to turnover. Attitudinal factors, such as job satisfaction and emotional well-being, are mediated via turnover intentions to effect actual turnover. Even accounting for methodological differences, this turnover rate is lower than previous studies, which use alternative methods and include part-time workers. This study should help nursing home administrators better understand the work-related factors associated with staff turnover.

Shy-Drager Syndrome Presenting as a REM Behavioral Disorder

Shy-Drager syndrome (SDS) is associated with a myriad of autonomic and neurologic impairments, including sleep dis turbances. A review of the literature reveals that there are no reports of SDS presenting with an abnormality of sleep. The following case report describes a patient who was diagnosed with SDS approximately one decade after initially presenting with a progressive, polysomnographically confirmed disturbance of sleep— specifically, an REM behavioral disorder (RBD).

Control-Relevant Intervention in the Treatment of Minor and Major Depression in a Long-Term Care Facility

The authors assessed the effect of a control-relevant psychosocial intervention in 31 nursing home residents with either major depressive episode or minor depression. An initial group of 22 residents were randomized to either active treatment or waiting list. Four of 11 residents randomized to active treatment were deemed Responders, compared with 0 of 11 on the waiting list (P < 0.05). Of the total of 31 residents who participated in the intervention, 14 (45%) were deemed Responders during the intervention period. For these Responders, the Hamilton Rating Scale for Depression (Ham-D) and Geriatric Depression Scale scores improved significantly during the intervention. The improvement in the Ham-D was not sustained 2 months after intervention was terminated. These findings suggest that a psychosocial intervention enhancing socialization according to each residents choice had a positive therapeutic impact on almost half of the nursing home residents with major or minor depression. However this effect could not be sustained by the residents without the support of the structured program.

An Open Pilot Study of Citalopram for Behavioral Disturbances of Dementia Plasma Levels and Real-Time Observations

Citalopram, in European studies, has shown some early promise for treatment of poststroke depression and behavioral complications of dementia. An open pilot study of citalopram was conducted in 16 patients with dementia and behavioral disturbances. Citalopram was well tolerated by 13 of the patients, and 9 had a clinically impressive response. A significant overall mean reduction in disruptive vocalizations was observed by means of a novel technique of computer-assisted real-time observation. The mean citalopram plasma level-to-dose ratio was found to be twice that previously reported in younger patients. These pilot findings should encourage future placebo concentration-controlled trials.