Truncal Fat and Frailty Are Important Predictors of Cognitive Performance among Aging Adults with Obesity.

OBJECTIVES: To explore associations among cognition, frailty, and obesity in older adults. DESIGN: Descriptive, secondary analysis of baseline data from two related lifestyle intervention trials. SETTING: Clinical study open to civilian population through the Center for Translational Research on Inflammatory Diseases at the Veterans Affairs Medical Center in Houston, TX. PARTICIPANTS: One hundred eight community-dwelling adults with obesity, aged 65 or older, recruited consecutively from two lifestyle intervention trials. MEASUREMENTS: Cognition was assessed using Composite Age-Adjusted Scale Score from the National Institutes of Health Toolbox Cognition Battery: Obesity was assessed by body mass index (BMI) and also by truncal fat mas via dual energy x-ray absorptiometry. Frailty was assessed using the Physical Performance Test. RESULTS: A significant linear regression model for cognition revealed frailty as the strongest predictor, followed by sex, and then truncal fat (R2=0.340, p<0.001). CONCLUSION: Cognition among community-dwelling older adults with obese BMI may worsen with greater truncal fat mass. Frailty appears to be an important predictor of cognitive performance in this population.

COPD education and cognitive behavioral therapy group treatment for clinically significant symptoms of depression and anxiety in COPD patients: a randomized controlled trial.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) affects 14 to 20 million Americans and is associated with increased prevalence of affective disorders, contributing significantly to disability. This study compared cognitive behavioral therapy (CBT) group treatment for anxiety and depression with COPD education for COPD patients with moderate-to-severe anxiety and/or depressive symptoms. METHOD: A randomized controlled trial (RCT) was conducted between 11 July 2002 and 30 April 2005 at the Michael E. DeBakey VA Medical Center, Houston, TX. Participants were 238 patients treated for COPD the year before, with forced expiratory value in 1 second (FEV)1/forced vital capacity (FVC)<70% and FEV1<70% predicted, and symptoms of moderate anxiety and/or moderate depression, who were being treated by a primary care provider or pulmonologist. Participants attended eight sessions of CBT or COPD education. Assessments were at baseline, at 4 and 8 weeks, and 4, 8 and 12 months. Primary outcomes were disease-specific and generic quality of life (QoL) [Chronic Respiratory Questionnaire (CRQ) and Medical Outcomes Survey Short Form-36 (SF-36) respectively]. Secondary outcomes were anxiety [Beck Anxiety Inventory (BAI)], depressive symptoms [Beck Depression Inventory-II (BDI-II)], 6-minute walk distance (6MWD) and use of health services. RESULTS: Both treatments significantly improved QoL, anxiety and depression (p<0.005) over 8 weeks; the rate of change did not differ between groups. Improvements were maintained with no significant change during follow-up. Ratios of post- to pretreatment use of health services were equal to 1 for both groups. CONCLUSIONS: CBT group treatment and COPD education can achieve sustainable improvements in QoL for COPD patients experiencing moderate-to-severe symptoms of depression or anxiety.

Views of hepatitis C virus patients delayed from treatment for psychiatric reasons.

For patients with chronic hepatitis C virus, certain psychiatric disorders are contraindications for antiviral therapy with interferon-alpha (IFN). Although these conditions delay a significant portion of patients from beginning therapy, no one has yet portrayed the views of these patients. A qualitative analysis, drawing upon semi-structured interviews, was developed to generate hypotheses regarding patient views of the treatment disposition process, and to generate strategies for increasing the portion of treatment-eligible patients. Two focus groups were conducted: one for patients delayed from treatment due to current or recent depression, and one for patients delayed due to current or recent alcohol use. A grounded theory analysis of the interview data were conducted. Patients were generally satisfied with the decision-making process, based largely on education from, and trust in, physicians. Upon learning their diagnosis, patients reported making healthy behaviour changes regarding alcohol, diet, exercise and herbal remedies. Some patients reported that requiring a period of alcohol abstinence was excessive, as they believed that they could discontinue alcohol use immediately, if so instructed by a physician. Patients seemed to over-interpret the likelihood of suicide during interferon-alpha (IFN) therapy. Current or recent psychiatric morbidity delays many patients from beginning interferon therapy. Nonetheless, this may be an optimal time for physicians to encourage healthy behaviours including abstinence from alcohol. Also, physicians may need to extensively assess the use of herbal remedies by patients. To help patients make judgments about beginning therapy, physicians should focus upon risk communication regarding the likelihood of suicide on therapy with interferon.

Utilization of emergency center services by older adults with a psychiatric diagnosis.

Information regarding older adult emergency center (EC) patient characteristics remains limited, despite its increasing importance in health care delivery systems. This retrospective study encompasses all EC visits over an eight-year period (n = 825,682) to a large urban county hospital. Only participants with a primary psychiatric diagnosis were examined, and included a total of 53,894 adults, 18-64 years old and 1,478 adults, > or =65 years old. Despite an increasing aging population, EC visits for older adults with psychiatric disorders did not increase over time. Within the older adult sample, cognitive, psychotic, and bipolar disorders were associated with higher rates of admission to the hospital, while substance use, depressive, and anxiety disorders were associated with lower numbers of inpatient admissions. African-Americans were over-represented in the EC and admitted to the hospital at higher rates, compared to other ethnic groups. Caucasian patients were the group most frequently diagnosed with a substance use disorder. In conclusion, differences in race, and diagnosis support the idea that such variables directly relate to utilization rates, presentation, and disposition within the EC.

Utility of a depression score to predict candidacy for hepatitis C virus therapy in veterans: a prospective longitudinal study.

BACKGROUND: The frequency and determinants of receipt of antiviral therapy once a diagnosis of a mood disorder is established in hepatitis C virus (HCV)-infected patients remains unknown. AIM: To examine the incidence and determinants of receiving antiviral therapy in HCV-infected veterans with abnormal scores of Zung Self-Rating Depression Scale (SDS). METHODS: We systematically evaluated the presence of psychiatric disorders among HCV-infected patients with initial referral between September 2000 and May 2002. We reviewed medical records, obtained history, and administered Zung SDS to evaluate for depressive symptoms. Patients with psychiatric disorders were referred for psychiatric evaluation. The primary outcome was the receipt of antiviral therapy during and after the initial evaluation up to December 1, 2003. The association between SDS scores and receipt of antiviral therapy was examined in a multivariate Cox proportional hazards regression. RESULTS: A total of 424 patients completed a Zung SDS. The scores were normal in only 43% of all patients, and were impaired mildly in 25%, moderately in 23%, and severely in 9%. Zung SDS scores were significantly higher in patients who served during the Vietnam War era, participated in combat, or had lower albumin levels. At the end of the first visit, 180 (42%) had psychiatric disorders. An abnormal Zung score (>55) was the only reason for referral to psychiatry in 83 of 180 patients; and in those 78 (94%) a formal psychiatric evaluation confirmed depressive disorder. Psychiatric disorders were the sole contraindication to therapy in 145 (34%) patients in whom eligibility for antiviral therapy was achieved in 42 (29%) during a mean follow-up duration of 27 months. CONCLUSIONS: Approximately one-quarter of patients with psychiatric disorders may become eligible for antiviral therapy following subsequent management of these disorders. The Zung self-screening test is an easy, valid method for detecting mood disorders in HCV-infected veterans.

Delirium: current trends in prevention and treatment.

Delirium is a disturbance of consciousness, cognition and perception that occurs frequently in medically ill patients. Although it is associated with increased morbidity and mortality, it is often not recognised and treated by physicians. Predisposing factors are believed to have multiplicative effects and include dementia, advanced age and male gender. Recently developed models allow for the estimation of the risk of developing delirium during a hospitalisation, based on predisposing factors and acute additional stressors. Although it has been shown to be efficacious, the prevention of delirium is underutilised. Prevention consists of aggressive management of known risk factors and early detection. Limited data exist to support specific pharmacological interventions for its treatment. In this article, the avail-able published literature regarding the prevention and treatment of delirium is systematically reviewed.

Psychological predictors of admission and discharge global assessment of functioning scale scores for geropsychiatric inpatients.

This study examined psychological predictors of Global Assessment of Functioning Scale scores (GAF) at intake and at discharge for geropsychiatric inpatients. A total of 301 predominantly male geropsychiatric inpatients were recruited from the Houston Veterans Affairs Medical Center. Path analysis was used to test a model proposing causal paths of psychological predictors (cognitive status, depression, agitation, general psychiatric status) to GAF scores on admission and discharge. At admission, all four psychological predictors had positive paths to the admission GAF scale scores but at discharge, only two (i.e., cognitive status and general psychiatric status) of the four psychological predictors had positive paths to the discharge GAF scale scores. The admission GAF scale scores also had a positive path to the discharge GAF scale scores. The overall functioning level of geropsychiatric inpatients may be predicted by measures which assess overall cognitive status and general psychiatric functioning during hospitalization. Results prompt consideration of a modified global scale specifically reflecting an older adult's activities during this period of life.

Measuring aggression in older adults: a latent variable modeling approach.

This cross-sectional measurement study demonstrates a technique for combining information from several aggression scales into one aggression score using latent variable modeling. Participants included male patients (n = 49) with a DSM-IV diagnosis of dementia at The Veterans Affairs Medical Center Outpatient Geriatric Psychiatry Clinic. Data from seven aggression scales were used to indicate the latent aggression variable. Results provided evidence that a unidimensional latent variable model of aggression adequately represented the data. Reliability of the aggression latent variable was estimated as 0.90, whereas reliability of the separate scales estimated with this sample were less than 0.84. Our findings suggest that combining multiple scales into one aggression score using latent variable modeling results in comprehensive and reliable aggression scores that offer researchers several advantages over current methods for measuring aggression.

Reminiscence and its relationship to attachment and personality in geropsychiatric patients.

The relationships between reminiscence functions and attachment styles; reminiscence and personality factors; and attachment and personality were examined in forty patients attending a geropsychiatric outpatient clinic. They were administered the Reminiscence Functions Scale, NEO-FFI, and the Relationship Questionnaire. Compared with insecurely attached older patients, securely attached older patients score higher on the teach/inform reminiscence function. Consistent with prior research, relationships were found between the extraversion personality factor and conversation reminiscence; and between the openness personality factor and both identity and problem-solving reminiscence functions.

One session cognitive behavioural therapy for elderly patients with chronic obstructive pulmonary disease.

BACKGROUND: We hypothesized that compared to an educational intervention, a single 2 h session of cognitive behavioural therapy (CBT), with 6-week follow-up, would reduce anxiety and depression, improve physical and mental functioning, and lead to a better quality of life and greater satisfaction with treatment in older patients with chronic obstructive pulmonary disease (COPD). METHODS: Fifty-six subjects were recruited from a large, urban, academically affiliated Veterans Affairs (VA) Hospital, a non-profit private hospital, and a local newspaper, for a single blind randomized controlled clinical trial. One 2 h session of group CBT was designed to reduce symptoms of anxiety, with specific components including relaxation training, cognitive interventions, and graduated practice, followed by homework and weekly calls for 6 weeks. This was compared to a group that received 2 h of COPD education, followed by weekly calls. Pre- and post-intervention subjects in both groups were administered SF-36, Geriatric Depression Scale, Beck Anxiety Inventory, 6 min walk test, and the FEV-1. Following the intervention, both groups completed the Client Satisfaction Questionnaire. RESULTS: When compared with a group that received education about COPD, 2 h CBT group showed decreased depression and anxiety. Contrary to our hypothesis, despite the decrease in depression and anxiety, there was no change in the physical functioning of the patients. CONCLUSIONS: Twenty to 40% of patients with COPD have high levels of anxiety and depression. Our study finds that as little as 2 h of CBT administered in a group setting is able to reduce these anxious and depressive symptoms.

Contribution of PTSD/POW history to behavioral disturbances in dementia.

As many World War II and Korean Conflict veterans suffering from posttraumatic stress disorder (PTSD) grow older, increasing numbers will be diagnosed with dementia. We retrospectively analyzed patients with dementia, comparing the behavioral disturbances of those with PTSD to those without PTSD. We hypothesized that due to the additive effect of the neurobiological and behavioral changes associated with PTSD and dementia, the dementia with PTSD group would show more agitation and disinhibition than the dementia without PTSD group. Sixteen patients with diagnoses of dementia and PTSD were matched on age and Mini-Mental States Examination (MMSE) scores to 16 patients with dementia without PTSD. Demographic characteristics, co-morbid diagnoses, global Assessment of Functioning (GAF), Cohen-Mansfield Agitation Inventory (CMAI), and paranoid items of Brief Psychiatric Rating Scale (BPRS) and Positive and Negative Syndrome Scale for Schizophrenia (PANSS) were assessed. The patients with diagnoses of dementia with PTSD did not differ significantly in their clinical presentation, hospital course, and condition at discharge from patients with dementia without PTSD. Chi-square analysis showed that significantly more subjects in the PTSD group were prescribed anti-depressants compared to the non-PTSD group. Interestingly, within the PTSD group, the subgroup of patients who were former prisoners of war had a significantly higher mean score for paranoia and significantly less verbal agitation. This pilot study reveals that a diagnosis of PTSD alone is not sufficient to influence behavior in veterans with dementia; however, we also present provocative results that patients with more severe trauma (POW) do have changes in their behavior.

Outcomes of decreased length of hospital stay among geriatric patients with dementia.

This study examined the outcomes associated with shortening hospital stays for geriatric inpatients with dementia at a Veterans Administration medical center. Thirty-three patients who were admitted after January 1997, when the hospital decided to reduce patients' lengths of stay, were matched with 33 patients who were admitted before January 1997. Despite significant differences in lengths of stay, no differences were found between the groups on measures of agitation or overall functioning. Despite significantly shorter stays since January 1997, the results of our study indicate that the cognitive and emotional status of patients discharged since that time are equivalent to those of patients discharged after longer hospital stays.

Tolerability and effectiveness of atypical antipsychotics in male geriatric inpatients.

The atypical antipsychotics are gradually becoming the mainstay of treatment for psychosis in the elderly. The present study examines the effectiveness and tolerability of risperidone and olanzapine treatment in 34 matched male patients admitted to a VA Medical Center geriatric inpatient unit. The Positive and Negative Syndrome Scale for Schizophrenia (PANSS), the Cohen-Mansfield Agitation Inventory (CMAI), the Rating Scale for Side-Effects, the Extra-Pyramidal Rating Scale, and the Mini-Mental State Examination were administered at admission and discharge. T-tests at admission and discharge across groups indicate that the patients as a whole were performing significantly better following their stay on the CMAI (t(30)=4.31, p=0.000), the GAF (t(31)=9.73, p=0.000), the PANSS total score (t(29)=3.82, p=0.001), and the positive symptom portion of the PANSS (t(28)=4.29, p=0.000). No significant differences were detected between the two groups with regard to length of hospitalization, or reduction in scores on the PANSS, or CMAI, however the daily cost of risperidone was 1/3 as much as olanzapine (p=0.00). The two treatments were comparable in the elderly men evaluated in this study.

Functional impairment in COPD patients: the impact of anxiety and depression.

The authors examined the relationship between functional status and comorbid anxiety and depression and the relationship between utilization of health care resources and psychopathology in elderly patients with chronic obstructive pulmonary disease (COPD). Elderly male veterans (N = 43) with COPD completed anxiety, depression, and functional status measures. The authors constructed regression models to explore the contribution of COPD severity, medical burden, depression, and anxiety to the dependent variables of functional impairment and health care utilization. Anxiety and depression contributed significantly to the overall variance in functional status of COPD patients, over and above medical burden and COPD severity, as measured by the 8 scales of the Medical Outcomes Study (MOS) 36-item Short Form Health Survey. Surprisingly, medical burden and COPD severity did not contribute significantly to overall variance in functional status. Few patients were receiving any treatment for anxiety or depression.

Informed consent and neuroanatomic correlates of intentionality and voluntariness among psychiatric patients.

The authors examine the less-studied components of patients' autonomous decision making, or decisional autonomy, in the light of current research in psychiatry and neuropsychology and developments in the construct of informed consent. The three components of decisional autonomy-understanding, intentionality, and noncontrol or voluntariness-are related to clinical constructs in psychiatry and neuropsychology, in particular to executive control functions. The authors review studies that examine deficits in prefrontal cerebral function in schizophrenia, depression, and some anxiety disorders that are related to intentionality and voluntariness. Assessment of decisional autonomy should encompass evaluation of impaired intentionality and voluntariness, not simply impaired understanding. The main response to finding such impairments should be to provide treatment to ameliorate them. New strategies for psychiatric care should be developed to address the clinical challenges of an increasingly complex view of decisional autonomy.

Assessment and understanding of pain in patients with dementia.

The literature on pain in dementia patients is reviewed. A summary of methods for assessment of pain in demented elderly persons and an examination of studies that used such methods are included. In addition, literature theorizing a decrease in affective pain in this population is discussed; management of pain in such patients is not discussed extensively. Research reveals 3 major findings: (a) a moderate decrease in pain occurs in cognitively impaired elderly persons, (b) communicative dementia patients' reports of pain tend to be as valid as those of cognitively intact patients, and (c) assessment scales developed thus far for noncommunicative patients require improvement in accuracy and facility. Many questions about pain in dementia patients remain, and the continued development of valid pain assessment techniques is a necessity.

Age-related differences in the frequency of personality disorders among inpatient veterans.

This cross-sectional study explored age-related differences in the frequency of diagnosis of personality disorder (PD) among 790 veterans admitted to a psychiatric inpatient unit across three age groups: 20-39, 40-59, and 60+. Older adults obtained a lower frequency (55.4%) of PD diagnosis than middle-aged adults (69.0%), who in turn obtained a lower frequency of PD diagnosis than young adults (75.9%). Older adults and middle-aged adults were less likely to receive a diagnosis of Borderline PD than young adults. Older adults were also less likely to receive a diagnosis of Mixed PD than young adults, but received significantly more diagnoses of Narcissistic PD than young adults. Patients diagnosed with PD had higher rates of psychiatric hospitalization than those with no diagnosis of PD. Older adults and middle-aged adults with PD had significantly fewer psychiatric hospitalizations than young adults with PD, whereas there were no age-related differences in the frequency of medical hospitalizations. These findings are consistent with research suggesting an overall softening of PD features with age, particularly those characteristic of the 'dramatic-erratic', Cluster B types.

Guardianship applications for elderly patients: why do they fail?

Variables associated with successful completion of guardianship applications for elderly patients were identified. Thirteen patients for whom applications were approved were compared with 26 whose applications did not reach the court. Patients for whom the process was successful scored significantly higher on the anergia-depression subscale of the Brief Psychiatric Rating Scale and had significantly more medical conditions in the past year. A survey of next of kin revealed that the process had a much better chance of success when the unit social worker made the guardianship recommendation and when family members were given more information about the taxing and time-consuming process of obtaining guardianship.

Clinical and ethical implications of impaired executive control functions for patient autonomy.

The authors identify the clinical and ethical implications of impaired executive control functions for patient autonomy. Executive control functions are processes that orchestrate relatively simple ideas, movements, or actions into complex goal-directed behavior, and impairments in these functions are becoming more common as the population ages. The authors examine difficulties that individuals with impaired executive control functions may have in making treatment decisions and describe a practical, ethically justified framework for making treatment decisions for patients with impairments in these functions. Three components of autonomy are identified-intentionality, understanding, and voluntariness. Intentionality and voluntariness are especially affected by impaired executive control functions. Impairments of these aspects of autonomy may often be overlooked when only traditional mental status examinations are employed, with adverse consequences for the health of patients wrongly thought to possess intact ability to make and carry out plans of care. Two case vignettes illustrate the complexities faced by clinicians intervening with patients who have deficits in decision-making capacity caused by impaired executive control functions.

Nonalcohol-related use disorders in geropsychiatric patients.

The authors determined the prevalence and demographic features of drug use disorders in a database of 565 veteran geropsychiatric inpatients. Twenty-four patients (4%) were diagnosed with nonalcoholic substance use disorders, including 18 (3%) with prescription drug use disorders and 6 (1%) with illegal drug use disorders. The patients diagnosed with prescription drug use disorders were predominantly Caucasian, whereas those diagnosed with illegal substance use disorders were predominantly African American. No other significant demographic differences were noted. Nonalcohol substance use disorders represent an unappreciated problem in psychiatrically hospitalized older adults, with illegal substance use disorders making up a larger than expected proportion of this group.