Sonne Lemke

Prognosis of older patients in mixed-age alcoholism treatment programs

Older patients were compared with matched groups of younger and middle-aged patients in inpatient alcohol treatment programs (N=432 in each age group). Compared with other patients, older patients had poorer physical health and lower cognitive status at treatment entry, but they were drinking less and reported fewer drinking-related problems, fewer psychological symptoms, more social support, more adaptive coping, and fewer barriers to abstinence. Older patients had positive views of the programs and, except for less family therapy and problem-focused counseling, received comparable treatment to that received by other patients. At discharge, older patients showed significant change in most areas targeted for treatment. Better initial status was the strongest predictor of better discharge functioning. Patients with higher cognitive functioning and stronger treatment motivation and those who experienced more interpersonal support and who received more specialized treatment services showed better-than-expected improvement. The age groups showed similar outcomes, prognostic factors, and response to different treatment orientations.

Closed-Eye Ocular Injuries in the Iraq and Afghanistan Wars

Comprehensive ophthalmic evaluation was conducted in 46 veterans hospitalized because of traumatic brain injury after blast exposure in Iraq or Afghanistan. Evidence of closed-eye injury was found in 20 of these patients.

Measuring the social climate of congregate residences for older people: Sheltered Care Environment Scale.

We developed the Sheltered Care Environment Scale (SCES) to provide researchers and practitioners with a practical means of assessing the social climate in congregate residential settings for the elderly. The SCES, a 63-item yes/no questionnaire that can be completed by residents and staff members of a facility, taps their perceptions of seven dimensions of the social environment. These dimensions concern the quality of relationships, the personal growth orientation present in the facility, and maintenance and change of the social system. The SCES discriminates among settings, has moderate to high internal consistency and split-half reliability, and is sensitive to environmental change against a backdrop of relative stability over time. The SCES reflects actual, agreed-on qualities of a setting and is relatively unaffected by characteristics of the respondent. Normative data are available from a national sample of 244 facilities representing the variety of residential settings available to the elderly.

Supportive Residential Settings for Older People

It is difficult to obtain accurate figures, but it is estimated that about 10% of the 24 million Americans over the age of 65 reside in specialized residential settings (Lawton, 1979; National Center for Health Statistics, 1979). These settings include nursing homes, which house about 1.1 million older poeple, and foster family and board and care homes, residential care facilities, congregate apartment housing, and some single room occupancy (SRO) hotels, which together house over one million older people. Some of these settings provide a full range of medical and personal care (skilled nursing facilities), some provide a moderate level of supportive services (residential care settings), and others offer only limited services, such as a meal plan (most congregate apartment houses and selected SRO hotels).

Visual quality of life in veterans with blast-induced traumatic brain injury

IMPORTANCE Traumatic brain injury (TBI) is an important cause of morbidity worldwide, with increasing awareness of the role of blast exposure in military and civilian casualties. Visual problems have been reported in TBI and may affect functioning and quality of life. OBJECTIVE To evaluate the 25-item National Eye Institute Visual Functioning Questionnaire and Neuro-Ophthalmic Supplement for utility in assessing the effect of blast exposure on perceived visual functioning among veterans with TBI. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study from a tertiary care Veterans Health Administration hospital. Reported visual quality of life was compared with existing norms, and relationships between perceived visual quality and ocular injury, diplopia, visual performance, and blast exposure characteristics were examined. Participants included inpatients with blast-induced TBI who underwent baseline examination between December 7, 2006, and January 11, 2012, at a multiple-trauma rehabilitation center and who had at least 1 intact eye and were able to undergo psychometric testing and ocular examination. Among 64 sequentially eligible patients, 60 completed visual quality testing, 1 declined study participation, and 3 were evaluated prior to inclusion of visual quality testing in the protocol. Thirty-nine patients returned for outpatient follow-up, with a median test-retest interval of 11 months. EXPOSURE Combat blast exposure with documented TBI. MAIN OUTCOMES AND MEASURES Composite and subscale scores on the 25-item National Eye Institute Visual Functioning Questionnaire and Neuro-Ophthalmic Supplement. RESULTS Both tests had high test-retest reliability. Blast-exposed veterans reported significantly poorer visual quality compared with healthy samples and some patient samples with known eye disease. Scores tended to be worse for participants with identified visual performance deficits (poorer visual acuity or spatial contrast sensitivity, visual field depression or defects). Scores were not related to the extent of ocular injury or to blast exposure characteristics such as use of protective eyewear or TBI severity level. CONCLUSIONS AND RELEVANCE Individuals with blast-induced TBI reliably completed both tests and reported significant decrements in their subjective visual experiences. Measures of subjective visual quality may be useful to identify patients needing additional visual or neurologic evaluation and to monitor the effect of visual rehabilitation on patients with blast-related visual disabilities.

Recent Changes in the Prevalence of Psychiatric Disorders Among VA Nursing Home Residents

OBJECTIVE This study identified recent changes in the prevalence of psychiatric disorders among Department of Veterans Affairs (VA) nursing home residents. METHODS Psychiatric diagnoses in administrative databases were summarized for nursing home residents in 1998, 2002, and 2006. Census prevalence rates were compared with findings from earlier VA nursing home surveys. Prevalence rates were compared for age groups and birth cohorts of VA nursing home admissions in 1998 (N=27,734) and 2006 (N=32,543). RESULTS Among residents in the census samples, prevalence rates for dementia and schizophrenia fluctuated moderately from 1990 to 2006, depression prevalence increased sharply, alcohol use disorder prevalence declined, and drug use disorder prevalence increased. Among 1998 and 2006 admissions, dementia prevalence increased for most birth cohorts but declined for most age groups (35% to 32% overall). Depression prevalence increased for all age groups and birth cohorts (27% to 37% overall), as did posttraumatic stress disorder prevalence (5% to 12% overall). Serious mental illness prevalence increased among the oldest residents and birth cohorts (19% to 22% overall). Alcohol use disorder prevalence declined for all birth cohorts and most age groups (18% to 16% overall), but drug use disorder prevalence increased substantially for younger age groups (6% to 9% overall). CONCLUSIONS Examining differences in prevalence between birth cohorts and age groups can clarify trends in nursing home resident characteristics and improve projections of their future needs.

The Multiphasic Environmental Assessment Procedure

Congregate settings for older people have evolved in a somewhat haphazard manner to meet a variety of perceived needs. Among these are the need for physical security and social contact for isolated older people, the need for personal care for those whose ability to care for themselves has declined, and the need for medical care for those with chronic physical or mental disabilities. Through such programs as Medicare and Medicaid legislation and the Federal Housing Acts, society has moved to take some responsibility for addressing these needs. This move has been accompanied by growing concern about regulating and improving conditions in these settings, studying their impact on residents, and planning better-quality housing for the future.

Visual Performance and the Ocular Surface in Traumatic Brain Injury

The pathophysiology of neurotrauma is reviewed and an original study investigating the prevalence of dry eye disease in a sample of veterans with traumatic brain injury (TBI) is presented. Fifty-three veterans with TBI were evaluated by history of injury, past ocular history, and medication use. Ocular Disease Surface Index (OSDI), ocular examination, cranial nerve evaluation, tear osmolarity, tear film break-up time (TFBUT), ocular surface staining and tear production testing were performed. A matched comparison group underwent similar testing. TBI causes were blast (44) or non-blast (9). TBI subjects scored significantly worse on the OSDI (P<.001), and ocular surface staining by Oxford scale (P<.001) than non-TBI subjects. Scores for tear film breakup (P=.6), basal tear production less than 3 mm (P=.13), and tear osmolarity greater than 314 mOsm/L (P=.15) were all higher in TBI subjects; significantly more TBI subjects had at least one abnormal dry eye measure than comparisons (P<.001). The OSDI related to presence of dry eye symptoms (P<.01). These effects were present in both blast and non-blast TBI. Seventy percent of TBI subjects were taking at least one medication in the following classes: antidepressant, atypical antipsychotic, anticonvulsant, or h1-antihistamine. There was no association between any medication class and the OSDI or dry eye measures. Reduced corneal sensation in 21 TBI subjects was not associated with OSDI, tear production, or TFBUT, but did correlate with reduced tear osmolarity (P=.05). History of refractive surgery, previous contact lens wear, facial nerve weakness, or meibomian gland dysfunction was not associated with DED. In summary, we found a higher prevalence of DED in subjects with TBI, both subjectively and objectively. This effect is unrelated to medication use, and it may persist for months to years. We recommend that patients with TBI from any cause be evaluated for DED using a battery of standard testing methods described in a protocol presented in this article. Further research into the pathophysiology and outcomes of DED in neurotrauma is needed.

Predictors of Anatomical Patency Following Primary Endonasal Dacryocystorhinostomy: A Pilot Study

Purpose: To identify factors influencing early anatomical patency following primary endonasal dacryocystorhinostomy (DCR) for nasolacrimal obstruction. Methods: A prospective study of 50 patients who underwent primary endonasal DCR for nasolacrimal obstruction was undertaken. Age, gender, dacryocystitis, endonasal access, clearance (bony clearance superiorly from the common canaliculus after bone removal), mobility (mobility of the flaps created from the lacrimal sac once opened), marsupialization (degree of reflection of the lacrimal sac following surgical opening) and a combined score (incorporating clearance, mobility and marsupialization) were examined. Outcomes were measured 10 weeks postoperatively by assessing anatomical patency via probe and syringe and modified functional endoscopic dye test. Results: Using the Kendall’s tau-beta test, there was a significant relationship between greater mobility and better outcome (p<.03) and greater marsupialization and better outcome (p=.03). A higher combined score (incorporating mobility, marsupialization and bony clearance) was also related to better outcome (p<.02). There was no significant relationship between outcome and age, gender, dacryocystitis, endonasal access or bony clearance. Overall, 47 patients (94%) had complete or partial patency at 10 weeks and 3 patients (6%) had complete nasolacrimal obstruction at 10 weeks. Conclusions: Greater flap mobility and greater lacrimal sac marsupialization in endonasal DCR are associated with better rates of early anatomical patency. A novel scoring system incorporating mobility, marsupialization and bony clearance also showed a significant relationship to early outcome, with higher scores being associated with better outcomes. These results may enable greater understanding of the perioperative features associated with better outcomes in endonasal DCR.

VA nursing home residents with substance use disorders: Mental health comorbidities, functioning, and problem behaviors.

Objectives: This research addresses whether residents with substance use disorders (SUDs) in VA nursing homes (VANHs) are distinctive in terms of their demographic characteristics, medical and mental health comorbidities, functioning, and problem behaviors. Methods: Residents over age 55 admitted to VANHs (n = 27,002) were identified in VA administrative files, and SUD and non-SUD residents were compared. Results: Compared with other residents, the residents with SUDs (18% of admissions over age 55) were more likely to be younger, male, African-American, unmarried, have low income and a tobacco use disorder. Controlling for demographic factors and smoking, SUD residents were more likely to have mental health comorbidities (dementia, serious mental illness, depressive disorders, and post-traumatic stress disorder), as well as AIDS/hepatitis, pulmonary disease, gastro-intestinal disorders, and injuries. SUD residents were less likely to have cancer, diabetes, neurological disorders, heart failure, and renal failure. SUD residents were more independent in activities of daily living, such as mobility and toileting. They were more likely to engage in verbal disruption but not in other problem behaviors such as aggression. With demographic factors and comorbidities controlled, the functioning differences were diminished, and SUD and non-SUD residents did not differ in the levels of problem behaviors. Discussion: VANH residents with SUDs have distinctive patterns of comorbidities and functioning. SUD appears to represent a separate risk factor for VANH admission. Residents with SUDs present challenges but may have good potential for positive discharge outcomes if their substance use problems and limited resources can be addressed.