The functional performance of elderly urban African-American women who return home to live alone after medical rehabilitation.

OBJECTIVE: Elderly women who live alone are at increased risk for loss of independence. Hospitalization, in particular, often marks the transition from independent living to institutional care. The purpose of this study was to examine the relationship of rehabilitation admission to the subsequent function of elderly women and their ability to return to live-alone status. METHOD: The women in the study (N = 138) were admitted to a geriatric rehabilitation unit at a large urban medical center between September 1997 and September 1998. The findings reported here pertain to the subset of African-American women (n = 122), the majority of the sample. Data were collected using several standardized assessments, including the Functional Independence Measure (FIM). RESULTS: The FIM motor scores improved significantly for the total sample between admission and discharge, and the mean FIM motor score for the group that subsequently attained live-alone status was significantly higher than the non-live-alone group at 3 months and 6 months postdischarge. The participants who returned to live alone also reported significantly greater independence than did their non-live-alone counterparts across a variety of activities of daily living and instrumental activities of daily living skills. CONCLUSION: These data suggest that rehabilitation is associated with improved functional outcomes, and higher functional performance is related to live-alone status.

Effective screening for Alzheimer's disease among older African Americans.

Relatively little data exist concerning the utility of brief cognitive measures to detect dementia among African Americans. The current study evaluated the clinical utility of the Mini-Mental Status Exam (MMSE) and the Fuld Object Memory Evaluation (FOME) in detecting Alzheimer's disease (AD) among both African American and European American older adults. One hundred and forty geriatric patients from a large urban academic medical center were examined. Overall, the FOME appeared to be more effective in detecting AD than was the MMSE (93% sensitivity vs. 75% sensitivity, respectively), although both measures suffered from relatively low specificity (63.5) in the full sample. The FOME demonstrated exceptional clinical utility among African American patients (sensitivity 98.3%; specificity = 64.5; positive predictive power 83.8%; negative predictive power 95.2%). The results of this study support the use of the FOME among older African Americans to detect dementia.

Environmental press and adaptation to disability in hospitalized live-alone older adults.

PURPOSE: This study examined the ability of personal competency variables at the time of hospital discharge to predict primary instrumental activities of daily living (IADLs) and secondary outcomes (living arrangements) in a sample of 194 urban, live-alone, older adults who had a new onset disability. DESIGN AND METHODS: Consecutively admitted medical rehabilitation patients, 72% women and 85% African American, participated in the study. Using path analysis, three of the four competency variables collected at the time of hospitalization (cognition, medical burden, activities of daily living) predicted IADLs at 3 and 6 months after hospitalization (e.g., cooking, telephone use, money management). IADLs, in turn, predicted living arrangements at 3 and at 6 months after hospitalization. RESULTS: The findings provided strong support for the importance of assessing a broad range of competency variables when investigating adaptation to disability. IMPLICATIONS: The increased understanding of adaptation in live-alone older adults with a new-onset disability is particularly timely given the increase in live-alone older adults and the dire consequences associated with change in living arrangement (i.e., mortality and morbidity) in this group.

Expanded normative data for the Mattis Dementia Rating Scale for use with urban, elderly medical patients.

Normative data for the Mattis Dementia Rating Scale (MDRS), stratified by age and education, are provided for use with older adults (ages 61-94) in urban medical settings. Age and education accounted for the greatest amount of variance in MDRS performance. Gender and race were also associated with total MDRS scores, though to a lesser extent. The present normative data are more appropriate for use with older patients seen in urban medical settings than normative data obtained from samples of better-educated, relatively healthy, Caucasian adults. This study provides additional evidence of the significant influence of age and education on MDRS total score (MDRS-T) performance, and highlights the importance of matching an examinee's demographic background to the normative sample with which his or her test score is being compared. Careful consideration of this match is likely to lead to more accurate diagnostic conclusions and potentially improved patient care.

Clinical utility of the Normative Studies Research Project test battery among vascular dementia patients.

The purpose of the present study was to examine the clinical utility of the Normative Studies Research Project test battery for detecting dementia with a known vascular component. The study compared 65 patients who had both suffered a stroke and met the DSM-IV criteria for dementia with 86 older medical patients who were cognitively intact. Multivariate analysis of covariance results demonstrated that these two groups had significantly different means on tests within the battery even after controlling for the influence of demographic variables. Logistic regression results demonstrated positive predictive value of 81.36%, negative predictive value of 85. 23%, and an overall correct classification rate of 83.67%.

The MacNeill-Lichtenberg Decision Tree: a unique method of triaging mental health problems in older medical rehabilitation patients.

OBJECTIVE: Evaluation of the utility of a "decision tree" that identifies potential mental health problems in older medical patients and guides decision making for referrals. DESIGN: Measures of utility including sensitivity, specificity, and predictive power were examined. Independent t tests and nonparametric statistics were used to evaluate group differences where appropriate. SETTING: The stroke and geriatric unit of a freestanding urban medical rehabilitation hospital. SUBJECTS: In study 1,173 older, consecutively admitted medical rehabilitation patients completed all cognitive measures. In study 2, a separate sample of 313 older adults completed the Geriatric Depression Scale during admission. MAIN OUTCOME MEASURE: The MacNeill-Lichtenberg Decision Tree (MLDT) was compared with the Mini-Mental State Exam (MMSE), the Mattis Dementia Rating Scale, and the 30-item Geriatric Depression Scale. RESULTS: Study 1: The decision tree accurately triaged 87% of mental health problems and allowed for deferral of 41% of cases, for whom further assessment was unnecessary. The MLDT was superior to the MMSE, with higher sensitivity and a lower failure rate. Study 2: The emotional status component of the MLDT was useful in triaging cases for depression evaluation. CONCLUSION: The MLDT was useful in prioritizing cases with regard to mental health problems (eg, dementia, depression) and making quick referral decisions. The MLDT is a unique instrument that not only evaluates cognitive status, but also considers psychosocial factors and emotional status in older adults.

Geropsychological problems in medical rehabilitation: dementia and depression among stroke and lower extremity fracture patients.

BACKGROUND: Although stroke and lower extremity fracture are often viewed as distinct medical rehabilitation conditions, they share similarities in that they are both experienced primarily among older adults, and are often accompanied by gero-psychological problems such as dementia and depression. In spite of these similarities, actual comparisons of these prevalence rates have been rare in the previous literature, most likely due to obvious differences in the nature of the injuries involved (neurological vs. peripheral injury). METHODS: One hundred and one stroke and 198 lower extremity fracture patients were assessed with neuropsychological tests from the Normative Studies Research Project test battery. The prevalence rates of dementia and depression were then compared between these two patient groups. RESULTS: Overall, 34.7% of stroke and 27.8% of lower extremity fracture patients met the criteria for dementia. In addition, 33.3% of stroke and 25.1% of lower extremity fracture patients scored in the depressed range on the Geriatric Depression Scale. The prevalence rates for dementia and depression did not differ significantly between these two patient groups. CONCLUSIONS: Although rehabilitation efforts focus mainly upon the primary diagnoses of geriatric patients, these findings suggest that stroke and lower extremity fracture should be considered within the context of the geriatric issues (e.g., dementia, depression, and comorbid medical illness) which accompany them.

Home alone: the role of cognition in return to independent living.

OBJECTIVE: To identify unique predictors of the ability to return to living alone in geriatric patients undergoing medical rehabilitation. DESIGN: Of 900 consecutive geriatric patients entering medical rehabilitation, 372 were identified as living alone before admission. Data were collected on functional status, cognition, demographics, and discharge disposition. SETTING: A freestanding medical rehabilitation facility. All patients were admitted to a geriatric rehabilitation unit. PATIENTS: Patients aged 60 to 99, identified as having lived alone before admission, were included. As standard procedure, patients underwent functional and cognitive assessment, and medical records were reviewed. MAIN OUTCOME MEASURE: Logistic regression analysis was used to evaluate predictors of discharge disposition, including demographic variables, medical burden, the Functional Independence Measure (FIM), and the Dementia Rating Scale (DRS). RESULTS: Both the FIM and DRS provided significant and unique variance in prediction of discharge disposition. Patients discharged home alone performed similarly to those discharged with supervision on FIM motor items but higher on FIM social cognition items, emphasizing the strong role of cognition in discharge disposition. Patients discharged home alone scored above suggested cutoff scores on the DRS, indicating generally intact cognitive functioning, whereas those discharged with supervision scored below suggested cutoffs. CONCLUSION: Results emphasize the importance of cognition in the ability to return to completely independent living after medical rehabilitation in geriatric patients.

Psychosocial factors related to unrecognized acute myocardial infarction.

Acute myocardial infarction (AMI) often is unrecognized (i.e., a patient fails to notice or report the event to the physician, or the physician fails to diagnose it). Psychosocial differences between patients with recognized and unrecognized AMI have not been examined. We compared 40 patients who sought treatment for a documented AMI with 30 patients who were found on routine electrocardiogram to have had an AMI for which they did not seek medical care. Patients with unrecognized AMI showed greater "alexithymia," or deficient psychologic awareness (p = 0.04; Alexithymia Provoked Response Interview), and a greater belief that chance factors determine their health (p = 0.004; Multidimensional Health Locus of Control Scale). Patients with unrecognized AMI were less likely to have angina, yet did not differ from those with recognized AMI with regard to demographics, smoking, systemic hypertension, diabetes mellitus, AMI location, depression, or hypochondriasis. We hypothesize that deficient psychologic awareness may impede AMI symptom perception or recognition, and that the belief in chance or fate as determining health may inhibit treatment-seeking.