Suicide in the elderly: how to identify and treat patients at risk.

Suicide rates among the elderly are the highest of any age group, perhaps as high as double the rate seen in the general population. White men over age 85 are at the greatest risk and are the target of a Healthy People 2000 objective. Aging and the changes it entails can often bring profound loss for older persons at a time when they are least able to handle it. Primary care physicians play a key role in recognizing depression among their elderly patients and in providing appropriate treatment. Therapies include antidepressants, ECT, and counseling. By identifying and treating depression, many suicides can be prevented.

The dizzy patient: stepwise workup of a common complaint.

Dizziness is a common and potentially disabling complaint among older patients. A major consequence of dizziness is falls, which can lead to death or significant functional disability. Dizziness can be separated into four broad categories: vertigo, disequilibrium, near-syncope, and nonspecific. Given its multitude of possible etiologies, dizziness often poses a diagnostic dilemma for the physician. Symptoms can result from a disturbance in any number of balance control systems, including the visual pathways, vestibular apparatus, cardiovascular system, and CNS. In evaluating dizziness, the physician should first obtain a careful medical history and perform a targeted physical examination. Depending upon the organ system involved, an audiologist, otolaryngologist, neurologist, cardiologist, and/or psychiatrist should then be consulted for further assessment and management.

Preventing HIV transmission: behavior and attitudes of medical house staff in a high-prevalence area.

Our objective was to evaluate human immunodeficiency virus (HIV) risk-factor assessment and counseling behavior in 86 medical house staff and to ascertain the effect of question format (closed versus open) on reported physician behaviors. We designed a cross-sectional survey using a self-report questionnaire; we received 78 returns of 86 questionnaires (91% response) from one-year and three-year medical housestaff at two general medical clinics in a university-affiliated Bronx municipal hospital. House staff reported assessing sexual behavior (51%) and intravenous drug use (81%) in new patients significantly less often than they assessed smoking (95%) or alcohol use (94%). Counseling to reduce the risk of HIV transmission among all patients occurred even less frequently (41%, all P < .05). Question format (closed versus open) significantly affected response rate; respondents to closed-format questions reported far more behaviors performed. Intravenous drug users (IVDUs) received more frequent advice than general clinic patients about reducing HIV transmission (85% versus 41%), but house staff may ignore sexual risks in IVDUs. Resident confidence that IVDUs would change sexual or drug risk behavior was equally low, 1.5 on a 4-point scale. They reported greater discomfort discussing sexuality than drug use (2.4 versus 1.7; 4-point scale, P = .003). Discomfort discussing sexuality inversely associated with sexual history-taking in multi-variate analysis. Greater involvement with HIV positive patients and fewer perceived barriers to counseling were also associated with more assessment or counseling about risks for HIV transmission. These results suggest that enhancing house staff assessment and counseling efforts to reduce risks for HIV transmission requires interventions that foster involvement with HIV positive patients, emphasize the importance of sexual transmission in IVDUs, facilitate competence in discussing sexual behavior, and address provider belief that IVDUs will not change risk behaviors. Results also demonstrate a significant effect of question format on reported physician behavior.