Reversible bronchial obstruction and disease-related health status in COPD.

We aimed to assess whether partially reversible and fixed airway obstructions are associated with different health status profiles of chronic obstructive pulmonary disease (COPD) patients. We characterized health status profiles of outpatients over 64 years suffering from COPD with fixed (n = 181) or partially reversible obstruction (n = 95) and from chronic bronchitis with forced expiratory volume in the first second (FEV1) > 69% of that predicted (n = 109) on the basis of the Saint George Respiratory Questionnaire (SGRQ) and indexes assessing cognitive (Mini Mental State), affective (15-item Geriatric Depression Scale) and physical status (Index of Barthel, six-minute walking test) and quality of sleep (Index of disturbed sleep). The degree of group-specificity of health status profiles was assessed by discriminant analysis. The 54.1% of COPD patients with partially reversible obstruction were recognized to have a distinctive health status profile characterized by a moderate to severe impairment of all components ('Symptoms', 'Activity', 'Impacts') of the SGRQ and of select indexes of performance. According to logistic regression analysis, this health status profile was associated with FEV < 46% of that predicted (odds ratio (OR): 1.6, 95% confidence interval (CI): 1.07-2.38), the use of at least three respiratory drugs (OR: 2.28, CI: 1.46-3.57) and living alone (OR: 2.01, 95% CI: 1.3-2.29). COPD patients with fixed obstruction had a very heterogeneous health status. Research is needed to verify whether the unfavorable health status profile typical of a subset of COPD patients is associated with a distinctive prognosis and can be improved by dedicated therapeutic interventions.

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 delta 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 delta MAC (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 in-hospital 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.

Verbal memory impairment in COPD: its mechanisms and clinical relevance.

STUDY OBJECTIVES: Identification of mechanisms accounting for verbal memory impairment in patients with severe COPD; assessing the relationship between verbal memory and the overall cognitive performance; verifying if verbal memory impairment affects medication adherence. DESIGN: Case-comparison study. SETTING: Outpatient Departments of Pneumology and Neurology, Day Hospital of General Surgery. PATIENTS: Forty-two COPD ambulatory patients, age 70+/-9.7 years, with hypoxemia and hypercarbia (group A); 27 normal subjects of comparable age and educational level (group B); 31 patients with Alzheimer's disease (group C); and 26 older normal subjects (group D). MEASUREMENTS AND RESULTS: The overall cognitive function and verbal memory were evaluated by the Mental Deterioration Battery and 14 indexes of verbal memory. Defective retrieval and recognition mechanisms distinguished group A from group B. According to discriminant analysis, verbal memory profile of COPD patients was group specific in 38.1% of cases and conformed to that of group B, C, and D in 19%, 16.7%, and 26.2% of cases, respectively. In COPD patients, both immediate and delayed recall, the strongest determinants of the discriminant function, were significantly correlated with the overall cognitive performance (rho=0.64, p=0.001; rho=0.61, p=0.001, respectively). Poor adherence to medication regimen was significantly associated with abnormal delayed recall score (82.3% vs 36% in subjects with normal delayed recall, p<0.008). CONCLUSIONS: Decline of verbal memory parallels that of the overall cognitive function in COPD patients and is due to the impairment of both active recall and passive recognition of learned material. It could be an important determinant of the level of medication adherence.

The interaction between age and comorbidity contributes to predicting the mortality of geriatric patients in the acute-care hospital.

OBJECTIVE: To test the predictive power of comorbidity and of the interaction between age and comorbidity in geriatric patients with acute medical illness. DESIGN: Prospective observational study. SETTING: Medical and geriatric wards of an acute-care hospital. SUBJECTS: Three hundred and seventy patients over 70 years of age consecutively admitted in an 18-month period. MAIN OUTCOME MEASURE: In-hospital mortality. METHOD: On admission a multidimensional assessment was performed, and a comorbidity index and an age-comorbidity index developed on a comparable training population were calculated. The comorbidity index is based upon a scoring system that quantifies the prognostic weight of individual diseases, while the age-comorbidity index corrects the former for the age-related increase of the risk of death. The predictive power of variables univariately correlated with the outcome was tested by logistic regression. RESULTS: Death was independently predicted by clinical diagnosis of malnutrition (odds ratio = 1.87, confidence limits CL = 1.20-2.86), age-comorbidity index > 7 (odds ratio = 1.77, CL = 1.15-2.72), preadmission impairment in activities of daily living (odds ratio = 1.74, CL = 1.13-2.69), lymphocytopenia (odds ratio = 1.74, CL = 1.15-2.61). A weaker predictive model was obtained by substituting the comorbidity index for the index of age-comorbidity. Excluding comorbidity from the logistic regression greatly weakened the predictive model.

Neuropsychologic effects of carotid endarterectomy.

This study assessed neuropsychologic changes after internal carotid endarterectomy using a design that limited the confounding effects of surgical and anesthesiological stress. Twenty-eight patients (mean age = 65.9 years, SD = 8.4, range 45-79), underwent extensive neuropsychological assessment before and on the seventh day after carotid endarterectomy for symptomatic carotid stenosis greater than 75%. A similarly assessed control group of 30 patients underwent elective orthopaedic surgery. A third cognitive assessment was performed 4 months postoperatively on a subgroup of the study patients. No significant cognitive change occurred in the control group. The study patients showed significant improvement in verbal memory, constructive abilities, verbal attainment, and visual attention; a trend towards further improvement of verbal functions was evident at the late postoperative assessment. No side-specific cognitive change was observed. In conclusion, carotid endarterectomy performed for currently accepted indications significantly improves several cognitive functions.

Energy intake and in-hospital starvation. A clinically relevant relationship.

BACKGROUND: Malnutrition is a common finding in the acute-care hospital. OBJECTIVES: To assess the adequacy of nutritional intake to individual needs and the effects of the hospitalization on nutritional status and to identify the reasons for inadequate energy intake. METHODS: A total of 286 patients with a mean ( +/- SD) age of 79 +/- 6 years (range, 70 to 99 years), consecutively admitted to the geriatrics and internal medicine wards of an acute-care university hospital, underwent multidisciplinary assessment on admission and at discharge and daily dietary data collection. The needed, prescribed, and actual daily energy intake for each individual was measured. Nutritional depletion was diagnosed if midarm circumference decreased by 3.6% or more from admission to discharge. RESULTS: Nutritional depletion occurred in 27% of the patients and correlated with anorexia (86.4% vs 65.5% and 40% in patients whose midarm circumference was unchanged and increased, respectively; P < .001), Mini-Mental State Examination score (21.6 +/- 8.3 vs 23 +/- 6.9 and 26.5 +/- 3.6; P < .05), simplified premorbid Activities of Daily Living score (4.4 +/- 2.2 vs 5.1 +/- 1.8 and 5.0 +/- 1.8; P < .03), lymphocyte count (1.32 +/- 0.63 x 10(9)/L vs 1.62 +/- 0.88 x 10(9)/L and 1.47 +/- 0.50 x 10(9)/L; P < .03), serum albumin level (38 +/- 5g/L vs 40 +/- 4 g/L and 39 +/- 8 g/L; P < .002), ratio of actual to needed energy intake (56.9% +/- 22.1% vs 69.3% +/- 30.4% and 60.0% +/- 14.1%; P < .01), ratio of actual to prescribed energy intake (50.5% +/- 16.9% vs 60.5% +/- 20.%% and 65.5% +/- 15.7%; P < .001). Patients who consumed less than 40% of the prescribed food complained of anorexia and masticatory inefficiency and were unsatisfied with quality and timing of meals compared with other patients. CONCLUSIONS: In-hospital starvation affects mainly patients with baseline nutritional, functional, and cognitive deficits and is strongly related to the inadequate energy intake.

Nutritional assessment: a primary component of multidimensional geriatric assessment in the acute care setting.

OBJECTIVE: To test the prognostic role of nutritional variables as a component of geriatric multidimensional assessment and to study the effect of hospitalization on nutritional status. DESIGN: Validation cohort study: multidimensional assessment on admission and at discharge and a weekly nutritional assessment. SETTING: General Medicine and Geriatrics wards in an acute-care university hospital. PATIENTS: A consecutive sample of 302 patients aged 79 +/- 6 years, range 70-96 years. MAIN OUTCOME MEASURES: Mortality, longstay (> 29 days), loss of lean body mass as expressed by a negative change in mid-arm muscle circumference (MAMC). RESULTS: Incidence of mortality, longstay, and decreased MAMC was 6.9%, 24.8%, and 64.2%, respectively. According to logistic regression analysis, mortality was independently predicted by preadmission dependency in at least one Activity of Daily Living (odds ratio = 2.08, confidence limits = 1.19-3.65), clinical diagnosis of malnutrition (OR = 1.89, CL = 1.11-3.21), serum albumin < 3.5 g/dL (OR = 1.82, CL = 1.06-3.14). This predictive model allowed us to recognize 75% of the patients at risk of death by targeting 23% of the population. Longstay was independently predicted by stroke (OR = 1.54, CL = 1.01-2.35), clinical diagnosis of malnutrition (OR = 1.41, CL = 1.04-1.93), and more than five comorbid diseases (OR = 1.39, CL = 1.01-1.94). Dependency in at least one ADL was the only independent predictor of decreased MAMC (OR = 1.71, CL = 1.27-2.30). CONCLUSIONS: Nutrition variables are a cardinal component of multidimensional assessment in the acute-care setting. Nutritional status deteriorates during the hospital stay, mostly in physically dependent patients.

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 Alzheimer's 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 Alzheimer's 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 Alzheimer's 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 Alzheimer's 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 Alzheimer's disease and contribute to define individual verbal memory profiles.

Predicting in-hospital mortality after hip fracture in elderly patients.

Ninety-seven patients aged 88 +/- 4 years (range, 80-97 years) (study group), and 74 aged 75 +/- 3 years (range, 70-79 years) (control group), were prospectively studied to investigate whether basic medical variables can predict in-hospital mortality in very old patients undergoing hip surgery because of femoral fracture. Mortality was 16.5% and 6.7% in the study and control groups, respectively (p = 0.054). In the study group, mortality was significantly correlated with age (p < 0.01), venous disorders (p < 0.05), malnutrition (p < 0.0001), duration of surgery (p < 0.006), and postoperative noninfectious complications (p < 0.005). In the control group, age was the only significant correlate of mortality (p < 0.005). After exclusion of surgery-related variables, the logistic regression analysis confirmed the predictive role of venous disorders (odds ratio = 2.04, confidence limits = 1.09-3.79) and malnutrition (odds ratio = 6.01, confidence limits = 1.85-19.47) but not of age in the study group. However, the goodness-of-fit test showed that the statistical model did not fit the data adequately. We conclude that in-hospital mortality after hip surgery in the very old cannot be predicted on the basis of underlying medical conditions alone.

Post-operative electrolyte imbalance: its incidence and prognostic implications for elderly orthopaedic patients.

In order to assess incidence and prognostic implications of post-operative electrolyte disorders for elderly patients, 180 patients aged 79.5 +/- 6.8 years, range 70-96 years, admitted to a geriatric-orthopaedic liaison service were prospectively followed from admission to discharge or death. The association of age, basic medical conditions, type of anaesthesia and perioperative complications with post-operative sodium/potassium imbalance and fatality was assessed by logistic regression analysis. The incidence of post-operative electrolyte imbalance and fatality was 15% and 8.8%, respectively. Electrolyte imbalance was independently predicted by spinal anaesthesia [odds ratio (OR) = 2, confidence limits (CL) = 1.24-3.19], multiple pathology (OR = 2, CL = 1.1-3.58), use of cathartics (OR = 1.76, CL = 1.05-2.91) and intra-operative complications (OR = 1.7, CL = 1.03-2.88). Death was predicted by electrolyte imbalance (OR = 2.32, CL = 1.21-4.43), post-operative noninfective complications (OR = 2.3, CL = 1.09-4.84) and age greater than 79 years (OR = 1.17, CL = 1.06-1.3). Post-operative electrolyte imbalance is a marker of very frail medical status and a risk factor for death among elderly orthopaedic patients.

Chronic obstructive pulmonary disease. An original model of cognitive decline.

In order to characterize the neuropsychologic profile of patients with hypoxic-hypercapnic chronic obstructive pulmonary disease (COPD), the performance of 36 patients with COPD 69 +/- 10 yr of age (mean +/- SD) on 19 tests exploring eight cognitive domains was compared with those of 29 normal adults (69 +/- 7 yr of age), 20 normal elderly adults (78 +/- 2 yr of age), 26 patients with Alzheimer-type dementia (72 +/- 6 yr of age), and 28 with multi-infarct dementia (MID) (70 +/- 8 yr of age). The discriminant analysis of cognitive test scores showed that 48.5% of patients with COPD had a specific pattern of cognitive deterioration characterized by a dramatic impairment in verbal and verbal memory tasks, well-preserved visual attention, and diffuse worsening of the other functions. The remaining patients with COPD were functionally classified as normal adults (12.1%), normal elderly adults (15.2%), those with MID (12.1%), and those with Alzheimer-type dementia (12.1%) according to discriminant analysis. Cognitive impairment was significantly and positively correlated with age (p < 0.05) and duration of hypoxic-hypercapnic chronic respiratory failure (p < 0.05). Because patients with COPD were receiving oxygen therapy from the beginning of oxyhemoglobin desaturation, results suggest that continuous oxygen therapy does not prevent or only partly prevents cognitive decline in COPD. Although some analogies between age-related and COPD-related cognitive decline are evident, a distinct cognitive profile was found in a large fraction of patients with COPD and it differs in several aspects from those of both normal and demented subjects.

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 > or = 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.

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.

Predicting mortality and length of stay of geriatric patients in an acute care general hospital.

Three-hundred-eight geriatric patients (mean age = 76.7 yr, range = 70-94 yr) consecutively admitted to an acute care general hospital were followed up to identify the predictors of in-hospital mortality and long stay. Sociodemographic, medical, and functional data were collected within 24 hours from admission and their correlation with the outcomes assessed by logistic regression analysis. The following variables were shown to be independent predictors of death: use of more than 6 drugs (odds ratio = 3.04, confidence limits = 1.05-8.76); abnormal Mini-Mental State score (o.r. = 1.72, c.l. = 1.05-1.83); low ADL score (o.r. = 2.4, c.l. = 1.07-5.56). Extended stay was significantly and independently predicted by polypharmacy (o.r. = 1.94, c.l. = 1.18-3.2) and comorbidity (o.r. = 2.06, c.l. = 1.24-3.38). The mortality rates of patients with cognitive impairment and polypharmacy with or without functional impairment were 40% and 22%, respectively. The proposed method allows identification of high-risk geriatric inpatients by a simple medical and functional assessment on admission.

A simple method of recognizing geriatric patients at risk for death and disability.

OBJECTIVE: To identify prognostic indicators for geriatric patients discharged from an acute care hospital. DESIGN: Prospective observational study. SETTING: Base line assessment at discharge from an acute care hospital; reassessment after 1 year at home. PATIENTS: One hundred-seventy-eight consecutive patients over 70 years of age (mean age +/- SD = 75.6 +/- 13.1 years, range 70-95 years, 52% males); 56% were dependent in one or more Activities of Daily Living, 21% had abnormal Mini Mental State Scores. MAIN OUTCOME MEASURES: mortality, increasing physical dependence, health care utilization. RESULTS: Mortality was directly related to a low ADL score at hospital discharges (Odds Ratio = 3.31, Confidence Limits = 1.91-5.75), neoplastic disease (OR = 3.59, CL = 2.01-6.43), cardiovascular disease (OR = 2.47, CL = 1.40-4.36), and drug use, expressed as the total number of individual preparations prescribed at discharge (OR = 1.72, CL = 1.05-2.83). Low ADL score, cardiovascular and neoplastic disease were also predictive of increasing physical dependency. The use of health care services, quantified by an appropriately designed score, did not correlate with any of the baseline variables, with the implication that the use of the health care services was not proportional to the need for care. CONCLUSIONS: Elderly subjects at major risk of death and disability can be easily identified at discharge by a simple assessment of their medical and functional state.

[Verification of the prognostic significance of a left-ventricular aneurysm after a first myocardial infarct]. / Verifica del significato prognostico dell'aneurisma del ventricolo sinistro dopo un primo infarto miocardico.

The prognostic implication of a left ventricular aneurysm after a first myocardial infarction has been assessed on a series of 64 patients (mean age 65 +/- 10 years; 55 males and 9 females) having a diagnosis of a left ventricular aneurysms made by the equilibrium gated radionuclide angiocardiography. The control group was composed by 80 patients (mean age 63 +/- 10 years; 65 males and 15 females) with first myocardial infarction and comparable clinical characteristics but without left ventricular aneurysm. Aneurysm was defined as a ventricular segment in phase with atria in the phase parametric imaging. A left ventricular ejection fraction less than 52% was diagnosed in 83% and in 49% of the patients with and without aneurysm respectively (p less than 0.0005). The study group also showed a higher use of digoxin (39% vs 21%; p less than 0.05) and a higher prevalence of ventricular arrhythmias (31% vs 12%; p less than 0.05). After 36 months, mortality was 34% and 17% in patients with and without left ventricular aneurysm, respectively (p less than 0.05). According to the logistic regression analysis, mortality was predicted by a left ventricular ejection fraction less than 52% (odd ratio = 1.91; confidence limits = 1.03-3.48) while neither left ventricular aneurysm nor any of the remaining variables (age, sex, site of the myocardial infarction, peak filling rate, congestive heart failure, ventricular arrhythmias and their Lown class) could affect survival. In conclusion, a left ventricular aneurysm has no prognostic implication after a first myocardial infarction provided that the patients are stratified for the left ventricular ejection fraction.

Right ventricular aneurysm: a new prognostic indicator after a first acute myocardial infarction.

The prognostic implication of a right ventricular aneurysm after a first acute myocardial infarction (AMI) was assessed on a series of 137 AMI patients 12 of whom had a right ventricular aneurysm detected at radionuclide angiocardiography. The follow-up lasted 36 months. Mortality was 50 and 18.4% in patients with and without right ventricular aneurysm, respectively (p less than 0.02). Groups did not differ in age, male-to-female ratio, AMI site, left ventricular ejection fraction (LVEF), peak filling rate (PFR), left ventricular size. A multivariate logistic analysis showed that only three out of ten clinical and functional variables qualified to be independent predictors of death: right ventricular aneurysm (odd ratio = 2.48, confidence limits = 1.21-4.98), LVEF less than 52% (odd ratio = 1.91, confidence limits = 1.03-3.48), abnormal terminal P wave forces (odd ratio = 1.72, confidence limits = 1.07-2.75). The analysis of single case histories did not provide a clue to clarify the reasons accounting for the negative prognostic implication of a right ventricular aneurysm. In conclusion, a significant positive relationship between right ventricular aneurysm and mortality after AMI has been demonstrated; further study is needed to clarify the relevant mechanisms.

Effects of hospitalization on affective status of elderly patients.

The effects of hospitalization on affective status were assessed by an original protocol in 214 consecutive elderly patients (mean age = 78.3 +/-5.0 years, range = 70-92 years). Psychological decompensation was significantly related to length of stay (p less than 0.01) and drug use (p less than 0.05) and unaffected by sex, marital status, prior living place, diagnostic category. Affective status and functional status were directly correlated (p less than 0.0001), although in 51% of medical patients the affective status worsened or remained unchanged despite improved physical function. Improvement in affective status occurred more frequently in surgical patients (p less than 0.001) due to psychological improvement following surgery. Physicians providing medical and surgical care for geriatric patients must remain aware of the patients' emotional response to hospitalization and illness, given the accompanying risk for psychological decompensation.