Living Unnoticed: Cognitive Impairment in Older People with Multimorbidity.

OBJECTIVES: To investigate the correlation between MMSE ≤ 23 and the presence of a diagnosis of dementia in the medical record in a population with multimorbidity. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study was part of the Ambulatory Geriatric Assessment - a Frailty Intervention Trial (AGe-FIT; N = 382). Participants were community dwelling, aged ≥ 75 years, had received inpatient hospital care at least three times during the past 12 months, and had three or more concomitant diagnoses according to the International Classification of Diseases, 10th revision. MEASUREMENTS: The Mini Mental State Examination (MMSE) was administered at baseline. Medical records of participants with MMSE scores < 24 were examined for the presence of dementia diagnoses and two years ahead. RESULTS: Fifty-three (16%) of 337 participants with a measure of MMSE had a MMSE scores < 24. Six of these 53 (11%) participants had diagnoses of dementia (vascular dementia, n = 4; unspecified dementia, n = 1; Alzheimers disease, n = 1) according to medical records; 89% did not. CONCLUSIONS: A MMSE-score < 24 is not well correlated to a diagnosis of dementia in the medical record in a population of elderly with multimorbidity. This could imply that cognitive decline and the diagnosis of dementia remain undetected in older people with multimorbidity. Proactive care of older people with multimorbidity should focus on cognitive decline to detect cognitive impairment and to provide necessary help and support to this very vulnerable group.

To adjust and endure: a qualitative study of symptom burden in older people with multimorbidity.

CONTEXT: Older people with multimorbidity are vulnerable and often suffer from conditions that produce a multiplicity of symptoms and a reduced health-related quality of life. OBJECTIVES: The aim of this study is to explore the experience of living with a high symptom burden from the perspective of older community-dwelling people with multi-morbidity. METHOD: A qualitative descriptive design with semi-structured interviews, including 20 community-dwelling older people with multi-morbidity and a high symptom burden. The participants were 79-89 years old with a mean of 12 symptoms per person. Data were analyzed using content analyses. RESULTS: The experience of living with a high symptom burden revealed the overall theme, "To adjust and endure" and three sub-themes. The first sub-theme was "To feel inadequate and limited". Participants reported that they no longer had the capacity or the ability to manage, and they felt limited and isolated from friends or family. The second sub-theme was "To feel dependent". This was a new and inconvenient experience; the burden they put on others caused a feeling of guilt. The final sub-theme was "To feel dejected". The strength to manage and control their conditions was gone; the only thing left to do was to sit or lie down and wait for it all to pass. CONCLUSION: This study highlights the importance of a holistic approach when taking care of older people with multi-morbidity. This approach should employ a broad symptom assessment to reveal diseases and conditions that are possible to treat or improve.

Tacrine and rate of progression in Alzheimer's disease--relation to ApoE allele genotype.

Today, cognitive impairment can be successfully treated with acetylcholine esterase inhibitors (AChE-I) in many, but not all, patients with Alzheimer's disease (AD). To investigate the relation between tacrine treatment, inheritance of ApoE epsilon4 alleles, and rate of progression, the differences in MMSE and CIBIC scores (efficacy parameters) after 6 and 12 months of tacrine (an AChE-I) treatment were investigated in 145 AD patients. Of these, 84 were ApoE epsilon4-positive (ApoE4) and 61 were ApoE epsilon4-negative (ApoE2-3). No differences were found after 6 months of treatment, but after 12 months the CIBIC scores revealed that the ApoE4 patients had declined more than the ApoE2-3 patients (p < 0.05). No differences were found for the last 6 months of treatment. The results primarily suggest a faster rate of decline in the ApoE4 AD compared to the ApoE2-3, but may also reflect that ApoE epsilon4 genotype inheritance is a negative predictor of treatment effect of tacrine in AD patients.

Report from the HLA class II typing by PCR-SSP Multicentre Study.

Results from 360 HLA-DR and -DQ 'low-resolution' typings with polymerase chain reaction sequence-specific primers (PCR-SSP), performed by nine laboratories, were analysed for their overall utility in routinely defining the HLA-DR1-DR18, DR51-DR53 and DQ1-DQ9 specificities in less than 2.5 h. Thirty EDTA blood samples and 10 DNA samples were distributed and analysed by each laboratory. DNA was extracted using a rapid bromide salt extraction protocol. Complete HLA-DR and -DQ typings were performed, three by three, on pre-aliquoted 96-tube PCR trays. When compared with reference typing, 351/360 (98%) correct DR typings were obtained, whereas 320/360 (89%) of the DQ phenotypes were correctly assigned. The time for three complete HLA-DR and -DQ 'low-resolution' typings, including DNA extraction, ranged from 2.0 h to 2.3 h. Unfortunately, an unusually high level of PCR amplification failures was observed (3%), probably due to diffusion and a significant volume loss from some of the pre-aliquoted primer mixes. Consequently, only 52% of the typings were without any amplification failure, and 0-2 amplification failures where found in 88% of the PCR-SSP typings performed. The number of HLA-DR-DQ retypings needed was 7 and 8%, respectively, reflecting the low number of typings where allelic identification was directly affected by the relatively high level of amplification failures in this study. Thus, a 91-98% success rate of correctly identified HLA-DR and -DQ alleles could be maintained, even under suboptimal typing conditions.

Recent trends in the development of alcohol and drug treatment services in Ontario.

This article summarizes the major trends in the development of alcohol and drug treatment services in Ontario since 1979. These trends are contrasted to the objectives of a province-wide Addiction Research Foundation (ARF) community development program designed to establish or expand addiction services within this same time period. Data were obtained from all treatment services in the province by surveys undertaken in 1980, 1983 and 1986. Across the period of analysis, there have been rapid increases in the number of addiction programs, their total cost and the total treatment caseload. Some specific changes have been quite consistent with ARF objectives: a stabilization in the use of hospital beds for addictions treatment, an increase in community-based versus hospital-based treatment resources, an increase in the province-wide capacity for comprehensive client assessment and a larger representation of women in addictions programs. Other ARF objectives have yet to be achieved. In particular, a major increase in nonresidential treatment alternatives and an increase in the proportion of treated cases from special populations such as youth or the elderly are still required. Suggestions are made concerning future program development.

The views of health and social service professionals regarding alcohol problems and their treatment.

A survey of health and social service professionals in one Ontario community suggested a generally high level of awareness of alcohol problems, reasonable optimism regarding the benefits of treatment, and positive attitudes toward an innovative assessment/referral service.

The use of two different pharmacological principles to inhibit a cholinergic bronchospasm in guinea pig.

The ability of inhaled atropine and clonidine to inhibit a bronchospasm produced by injected acetylcholine or by vagal stimulation, was studied in anaesthetized guinea pigs. Vagally mediated airway constriction was restrained in a concentration-related fashion by inhaled clonidine and reached nearly 100% inhibition (EC50 = 2 X 10(-5) mol/l in the nebulizer). Atropine expressed initially about the same level of spasmolytic effect but only a final prevention of 60% was possible to reach with this drug. On the contrary, inhaled atropine was able to produce a complete inhibition (EC50 = 2 X 10(-6) mol/l) when the bronchoconstriction was elicited by exogenous acetylcholine. This type of spasm was also to some degree inhibited by clonidine.