R. Antonelli Incalzi

Predicting cognitive decline in patients with hypoxaemic COPD

The objective was to identify predictors of cognitive decline in patients with hypoxaemic COPD on continuous oxygen therapy. Eighty-four consecutive ambulatory hypoxaemic COPD patients in stable clinical conditions were prospectively studied over the course of 2 yr. Baseline multidimensional assessment included respiratory function tests, blood gas analysis, Mini Mental Status (MMS) test, Geriatric Depression Scale (GDS), Activities of Daily Living (ADLs) and Charlsons index of comorbidity. Reassessments were made 1 yr and 2 yr thereafter. Sequential changes in MMS, GDS and ADLs were assessed by Friedmans ANOVA by rank test. Forty patients completed the study (group A), while 44 died or were lost to follow-up (group B). Group B was characterized by more severe respiratory function impairment and worse performances on ADLs and GDS. In group A, MMS deteriorated from baseline to the 1 yr and 2 yr reassessments (27 +/- 2.9 vs. 25.8 +/- 4.1 and 25.4 +/- 4, P < 0.005), whereas GDS and ADLs did not change significantly; the 23 patients experiencing a decline of MMS had baseline lower percentage predicted FVC (52.3 +/- 17.1 vs. 66.9 +/- 13.4, P < 0.03) and FEV1 (27.2 +/- 8.6 vs. 44 +/- 26.8, P < 0.02) values and better affective status (GDS score: 11.9 +/- 7.7 vs. 16.5 +/- 5.6, P < 0.04). Two-year changes in MMS and in GDS scores were inversely correlated (Spearmans p = -0.32, P = 0.04). Cognitive decline is faster in the presence of severe bronchial obstruction and parallels the worsening of the affective status in COPD patients on oxygen therapy. The onset of depression rather than baseline depressive symptoms seems to be a risk factor for cognitive decline.

Verbal Memory Impairment in Congestive Heart Failure

Cognitive dysfunction, mainly memory impairment, characterizes congestive heart failure (CHF). Aim of this study was to verify whether: (1) CHF has differential effects on primary and secondary memory; (2) memory dysfunction can be diagnosed by a screening instrument. In a multicenter study we enrolled 369 patients with stable CHF who underwent a structured assessment of verbal memory mechanisms and selected cognitive functions. Performance on some verbal memory indexes (Recency, Reys immediate and delayed recall, Learning efficiency) progressively decreased from II to IV New York Heart Association (NYHA) class. Rate of forgetting was uniformly high across NYHA classes II–IV. Verbal memory indexes were highly correlated with most nonverbal scores. The Mini Mental State Examination (MMSE) had poor sensitivity and specificity versus primary or secondary verbal memory dysfunction. Therefore, a deficit of both primary and secondary memory is relatively common in CHF but cannot be accurately recognized by a screening neuropsychological test.

Continuous geriatric care in orthopedic wards: A valuable alternative to orthogeriatric units

The aim of this study was to assess whether assigning a geriatrician to provide daily medical care to geriatric patients in the orthopedic ward can improve the prognosis and reduce the length of stay. Time series analysis was performed in two parts: (1 prospective analysis of two years’ workload, and 2) retrospective analysis of data collected over the 4 years prior to the intervention. Intervention and control populations were pooled, and the effects of geriatric care and patient- related factors on outcome measures were assessed by logistic regression analysis. All subjects were patients aged ⩾ 70 years who attended the orthopedic ward in a university hospital in years 1989–90 (studied group: 287 cases) and in years 1985–88 (control group: 474 cases). In the study period, mortality was 8.4% compared to 18% in 1985–86 (p<0.0006) and 14% in 1987–88 (p<0.01). The operation rate in the study period was 89.9% vs 83.8% in 1985–86 (p<0.02) and 81.8% in 1987–88 (p<0.005). Length of stay was 26.2± 14.4 days vs 32.9± 30.9 days in 1985–86 (p<0.05) and 26.9± 16.5 days in 1987± 88 (NS). Length of stay was more strikingly shortened in the subset of patients with femoral fracture undergoing surgical management (28.5± 12.7 vs 37.6± 32.6 days in 1985–86, p<0.003, and 30.8± 15 days in 1987–88, p<0.02). Given the positive relationship between geriatric care and operation rate (o.r.=1.5, CI=1.1–1.9), the protective effect of surgical treatment on mortality (o.r.=0.6, CI=0.4–0.8) to some extent may mask the collinear effect of geriatric care. We conclude that assigning a geriatrician to assist with the medical care of elderly orthopedic patients in orthopedic wards is associated with increased operation rate, decreased mortality and shortened length of stay. (Aging Clin. Exp. Res. 5: 207- 216, 1993)

Construct Validity of the 15-Item Geriatric Depression Scale in Older Medical Inpatients

The construct validity of the 15-item Geriatric Depression Scale (sfGDS) has been assessed in selected populations. The aim of this study was to assess the appropriateness of applying the sfGDS to unselected older inpatients. The main component analysis of sfGDS was performed in 2032 medical inpatients (mean age = 76.3 ± 8.4). sfGDS did not qualify as a unidimensional test. Three factors explained 47.7% of variance and explored the following dimensions: positive attitude toward life, distressing thoughts/negative judgment about the own condition, and inactivity/reduced selfesteem. The internal homogeneity was poor (Cronbach’s α = .46). A higher fraction of variance was explained in patients independent in all or dependent in ≥ 1 activity of daily living (ADL). In older medical inpatients, sfGDS is not a single construct, which prevents the univocal interpretation of the final score. The higher fraction of explained variance in patients with comparable ADL performance probably reflects the dependency of affective from physical status. (J Geriatr Psychiatr Neurol 2003; 16:23-28)

Effects of aging and of Alzheimer's disease on verbal memory.

This study aimed to define the verbal memory profiles of very old normal subjects and subjects with Alzheimers Disease, and to identify verbal memory indices having the highest discriminant power. Forty-three old normal subjects (mean age = 71 years, SD = 3, range = 65-75), 39 very old normal subjects (mean age = 81 years, SD = 4, range = 76-87), and 45 Alzheimers patients (mean age = 70 years, SD = 5, range = 59-78) received the Rey test of verbal memory and the WAIS-R Digit Span forward and backward. All but one of the indices could distinguish very old from Alzheimers subjects. A discriminant analysis disclosed a verbal memory profile of Alzheimer type in 15.4% of the very old group and of very old type in 16.2% of the Alzheimers patients. Rate of forgetting, immediate and delayed Rey indices, and the true positive responses were, in decreasing order, the main determinants of the discriminant function. Thus, all of the components of verbal memory are differently affected by aging and Alzheimers disease and contribute to define individual verbal memory profiles.

Construct Validity of the Abbreviated Mental Test in Older Medical Inpatients

Objectives: To evaluate validity and internal structure of the Abbreviated Mental Test (AMT), and to assess the dependence of the internal structure upon the characteristics of the patients examined. Design: Cross-sectional examination using data from the Italian Group of Pharmacoepidemiology in the Elderly (GIFA) database. Setting: Twenty-four acute care wards of Geriatrics or General Medicine. Participants: Two thousand eight hundred and eight patients consecutively admitted over a 4-month period. Measurements: Demographic characteristics, functional status, medical conditions and performance on AMT were collected at discharge. Sensitivity, specificity and predictive values of the AMT <7 versus a diagnosis of dementia made according to DSM-III-R criteria were computed. The internal structure of AMT was assessed by principal component analysis. The analysis was performed on the whole population and stratified for age (<65, 65–80 and >80 years), gender, education (<6 or >5 years) and presence of congestive heart failure (CHF). Results: AMT achieved high sensitivity (81%), specificity (84%) and negative predictive value (99%), but a low positive predictive value of 25%. The principal component analysis isolated two components: the former component represents the orientation to time and space and explains 45% of AMT variance; the latter is linked to memory and attention and explains 13% of variance. Comparable results were obtained after stratification by age, gender or education. In patients with CHF, only 48.3% of the cumulative variance was explained; the factor accounting for most (34.6%) of the variance explained was mainly related to the three items assessing memory. Conclusion: AMT >6 rules out dementia very reliably, whereas AMT <7 requires a second level cognitive assessment to confirm dementia. AMT is bidimensional and maintains the same internal structure across classes defined by selected social and demographic characteristics, but not in CHF patients. It is likely that its internal structure depends on the type of patients. The use of a sum-score could conceal some part of the information provided by the AMT.

Unrecognized dementia: sociodemographic correlates.

Eighteen geriatric patients, aged 77± 8 years, in whom a diagnosis of dementia was formulated during an unrelated hospital stay, were studied to clarify why dementia had not been detected at an earlier stage. The control group was composed of 20 patients aged 79± 11 years with a comparable degree of cognitive impairment who had been recognized 1–3 years previously. The index group was characterized by a lower formal education (5.2± 3.7 years vs 8.5± 4.7 years, p<0.05), and higher prevalence of subjects living in rural areas (50% vs 10%, p<0.006); other sociodemographic variables (age, sex, marital status, employment before retirement) could not distinguish the groups. A multivariate logistic regression analysis showed that the end point late diagnosis was significantly correlated with the independent variables, rural residence (odds ratio=4.65, C.I.=1.7–12.9) and lower occupational role (odds ratio=3.3, C.I.=1.2–9.5). A structured interview with relatives of the patients disclosed 3 main reasons accounting for later diagnosis: poor awareness of the problem of dementia; respect for parents and grandparents; and negligible effect of this problem on family life and economy. In the control group, dementia had been diagnosed earlier mostly because of its heavier social and economic impact on the family. (Aging Clin. Exp. Res. 4: 327–332, 1992)

Changes in nutritional status during the hospital stay: a predictor of long-term survival.

The objectives of this prospective observational study were to assess whether: 1) midarm circumference (MAC), previously shown to predict in-hospital mortality, maintains its prognostic implication after discharge; 2) in-hospital changes in aspecific indicators of the health status are predictors of long-term survival. The study population consisted of 249 patients from the general community [mean age 80±7 (70–99) years], consecutively discharged from geriatric and medical wards of an acute care hospital. Changes in health status during hospitalization were recorded (dynamic or δ variables) and health-related variables were collected at discharge (discharge variables). The relationship of both sets of variables to survival over a 3-year period was assessed by Cox’s proportional hazards regression analysis. The discriminatory efficacy of predictive models was estimated by the Hanley and McNeil method. Survival curves were drawn with the patients alternatively grouped according to the presence or absence of each of the predictive variables. Serum albumin<3.5 g/dL (hazard rate=0.57, 95% confidence limits=0.33–0.96) and dependency in at least one ADL (h.r.=0.87, c.l.=0.79–0.98) were found to be associated with increased mortality, and δMAC (h.r.=1.03, c.l.=1.01−1.05 ), i.e., there was a positive change or no change in MAC from admission to discharge, with increased survival. A slightly weaker predictive model was obtained using only discharge variables. However, Hanley and McNeil’s analysis showed that both models were far from achieving the optimal discrimination of high from low risk subjects. Effects on survival of individual variables varied in magnitude and dependency on time. We concluded that measuring inhospital changes in nutritional status might improve prediction of long-term survival. Attempts should be made to identify variables having the strongest prognostic implications, and to tailor dynamic assessment to the needs of selected categories of patients.

ACE INHIBITORS : A POSSIBLE CAUSE OF UNEXPLAINED ANEMIA

In reply: We are fairly certain that we are in substantial agreement with these authors. However, we need to clarify some of our points. Can prognosis be used to deny treatment to a patient who wants it? This is often referred to, futilely, as the “futility debate.” The authors seem to assume that this can be done. Many people disagree the majority of respondents in their study, for example. We believe that sometimes people who are irretrievably near death can be cared for by their doctors without full disclosure of the menu of ways to die or of the possible treatments available. Many philosophers and some clinicians believe this is a serious abridgment of autonomy. And we, of course, believe that sometimes attempted cardiopulmonary resuscitation (ACPR) is simply the wrong thing to do. In some cases, we would not inflict autonomy, and when death came we would accept it. We often disagree in individual cases, but we agree on the principle. What the authors summarize as their “first do no harm” viewpoint actually corresponds to our “restraint” viewpoint, “emphasizing the burdens of ACPR compared with the very small likelihood of benefit.” (The Jezebel” viewpoint was intended only to “emphasize an aversion to vigorous handling of the corpse.” We are not Bible scholars and so did not know that Jezebel was “thoroughly evil” and deserved to be eaten by dogs. By the way, doesn’t the word desecrated imply some human intent? Or do we feel that buried bodies are routinely desecrated by bacteria?) We wrote that a resource allocation underlay Policy 2: Staff does not do ACPR, but emergency services will be called. If these facilities are really trying to “first do no harm,” as the authors suggest, does it make sense then to call 911 and let ambulance staff do the harm? Careful reading of the two papers shows, we believe, near total agreement. A resurvey of these nursing homes early in the next millenium could be very interesting. Perhaps there will be a shift in the policies. We doubt there will be a convergence, however, because facilities are heterogenous and because these are life and death matters.