Richard K. Morycz

Caregiving Strain and the Desire to Institutionalize Family Members with Alzheimer's Disease Possible Predictors and Model Development

This research explores whether the strain experienced by caregivers of relatives with Alzheimers disease will be strongly related to the desire of families to institutionalize their older members. The desire of a caregiver to institutionalize a patient with Alzheimers disease was found to be greater when the caregiver experiences increased strain or burden, when a patient is widowed, when there is more physical labor involved in caregiving tasks, and when the patient lives alone. Intensity of family strain (or felt stress) can best be predicted by the availability to the caregiver of social support: Less support implies more strain. However, for male caregiving groups and for all black caregivers, strain does not play a significant role in predicting the desire to institutionalize.

EEG sleep in elderly depressed, demented, and healthy subjects

In a prospective study of EEG sleep patterns in 25 elderly depressives, 25 elderly demented patients, and 25 healthy, elderly control subjects, the sleep of depressives was characterized by reduced REM sleep latency, increased REM percent and first REM period density, and altered temporal distribution of REM sleep, as well as by diminished sleep maintenance (correlated significantly with Hamilton ratings of depression: multiple R = -0.42, p less than 0.05). In contrast, the sleep of demented patients showed reduced REM sleep percent, but normal REM temporal distribution, increased loss of spindles and K-complexes (the latter correlating significantly with severity of cognitive impairment as measured by the Folstein score: multiple R = -0.59, p less than 0.01), and less severe sleep maintenance difficulty than for depressives. An examination of REM latency demonstrated a skewed distribution in depression (i.e., 42% of nights with sleep-onset REM periods), but a normal distribution in the controls and demented subjects. A REM latency cut-off score of 30 min correctly classified 68% of all patients (kappa = 0.36; p less than 0.005), compared with 78% correctly identified in our retrospective study (Reynolds et al. 1983).

Predictors of In-Home and Out-of-Home Service Use by Family Caregivers of Alzheimer's Disease Patients

Few studies have examined whether the use of different types of services is predicted by different characteristics of elderly care recipients and primary kin caregivers. Most research aggregates services into a single category, thereby assuming that different services have the same predictors. This investigation differs from the aggregation approach by comparing four groups of elderly care recipients: in-home service of users, out-of-home service users, users of both in- and out-of-home services, and those who do not use services. Data come from personal interviews with 171 family caregivers of mild to moderate dementia patients who reside in the community. Using the modified Andersen framework and multiple group discriminant analysis, results show that care recipients who do not use services and those using only in-home services have inadequate informal supports, more emotionally strained caregivers, and more functionally impaired care recipients compared with users of out-of-home or both in- and out-of-home services.

Elders with dementia living in the community with and without caregivers: an epidemiological study.

BACKGROUND Previous studies of dementia and family caregiving have focused on individuals seeking diagnosis and treatment, and have rarely been conducted in representative community samples. Identifying demented individuals participating in a community survey, we determined (a) the factors associated with demented elderly living alone; (b) the factors associated with the demented elderly having caregivers; (c) the factors associated with increased levels of burden among caregivers of persons with dementia. POPULATION AND METHODS During an epidemiological survey of a mostly rural U.S. community, the authors identified 116 noninstitutionalized elderly individuals with dementia. These individuals were classified into those living alone and those living with others; both groups were further classified into those with and without identifiable family caregivers. Characteristics of both caregivers and care recipients were examined. RESULTS Approximately a third of the subjects with dementia lived alone, and only half of them had caregivers. The average age of the caregivers was 67.4 years, and 73% of them were women. Almost half of the caregivers were spouses, whereas almost a third were offspring, of the demented individuals. Over two thirds of caregivers lived with the subjects. Female caregivers were significantly younger than male caregivers. Multivariate analyses revealed that subjects with dementia who were living alone were independently and significantly more likely to be women and to have dementias of shorter duration, lesser severity, and lesser functional impairment than those living with others. Demented subjects with caregivers were more likely to have greater dementia severity, functional impairment, and cognitive impairment and more current cognitive and behavioral symptoms than those without caregivers. Demented subjects whose caregivers reported higher levels of burden were more likely to be women and to have greater dementia severity, functional impairment, and cognitive impairment and more current symptoms than those whose caregivers had no/minimal burden. CONCLUSIONS These results draw attention to the problems of persons with dementia living alone, particularly those without caregivers. Our data also provide epidemiological confirmation of previous clinical/volunteer studies of dementia caregiving, as well as a preliminary assessment of need in the community at large. Living arrangements and caregiver issues should be taken into account when planning services for the elderly.

Elevated red blood cell/plasma choline ratio in dimentia of the Alzheimer type: Clinical and polysomnographic correlates

In a prospective study we have observed a shift in distribution of red blood cell (RBC)/plasma choline ratios among patients with probable dementia of the Alzheimer type (DAT), compared with healthy controls and depressed patients. Fifteen of 22 DAT patients (68%) showed RBC/plasma choline ratios greater than 1.9, in contrast to 9 of 26 healthy controls (35%) and 7 of 20 depressives (35%). These significant differences confirm and expand earlier observations. The subgroup of DAT patients with elevated RBC/plasma choline ratios is older and more cognitively impaired, shows later onset of dementia, and has less rapid eye movement (REM) sleep than the DAT subgroup with normal RBC/plasma choline ratios. Within the entire group of DAT patients, moreover, the RBC/plasma choline ratio shows a significant inverse correlation with REM sleep latency. These findings are discussed in relation to abnormalities in other nonneural Alzheimer tissues and within the context of cholinergic involvement in both DAT and the timing of REM sleep.

Open-trial maintenance pharmacotherapy in late-life depression: Survival analysis

We report preliminary findings from an ongoing, open trial of maintenance nortriptyline pharmacotherapy in 27 elderly depressed patients (median trial length: 18 months). While patients were on maintenance nortriptyline (mean dose: 50 mg/day) with steady-state plasma levels in the range of 50-150 ng/ml, 58% of Q-6 monthly ratings on the Hamilton Rating Scale for Depression have been 10 or lower, Folstein Mini-Mental State ratings have remained above 27, and a minimal level of side effects with no increase over time has been observed. Four of 27 patients (14.8%) have suffered recurrences and have required rehospitalization at 6, 9, 10, and 13 months. Survival analysis showed an 85% survival rate (without recurrence) at 12 months and 81.5% at 18 months. Mean survival time without recurrence is 21.3 months to date. Although our pilot experience with maintenance nortriptyline in late-life depression appears more favorable than outcomes reported in earlier naturalistic studies (where no attempt was made to keep patients in systematic maintenance therapy), the need for controlled studies of maintenance therapies in late-life depression is nonetheless underscored by the current data and other naturalistic data from the United Kingdom.

Morbidity of Homebound Versus Inpatient Elderly Psychiatric Patients

This study compares the demographic and clinical characteristics of homebound (HB) elders referred for psychiatric services (N = 251) with those of inpatients (IP) admitted to a geriatric psychiatry unit (N = 594). Demographically, HB patients were older (78.8 vs 74.7 years), were more likely to be women (83% vs 68%), were widowed (54% vs. 44%), and had fewer years of education (10.3 vs. 11.1), but were similar in race, income, and proportion living alone. Clinically, HB patients had less functional disability, less severe depression, less cognitive impairment, and fewer medical problems. However, they were similar in the distribution of most psychiatric diagnoses except dementia (higher in the IP group) and dementia with depression (higher in the HB group). Outcome data for the HB group over 15 (range, 1 to 38) months revealed medical hospitalization in 20.7%, psychiatric hospitalization in 16.3%, nursing home placement in 9.2% and mortality in 8.4%. These preliminary data show that the HB group had psychiatric problems that were comparable to those of the IP group but were not as severely impaired.