The utility of the Stroke Aphasia Depression Questionnaire (SADQ) in a stroke rehabilitation unit.

OBJECTIVE: To determine the utility of an observer-based rating scale to detect depression in patients without aphasia. DESIGN: Correlation analysis between the Stroke Aphasia Depression Questionnaire, shortened version (SADQ-10) and a validated self-rating measure of depression, the Geriatric Depression Scale (GDS). The sensitivity and specificity of the SADQ-10 were also calculated. SETTING: Stroke rehabilitation unit. SUBJECTS: Sixty-five stroke patients without significant aphasia undergoing rehabilitation. INTERVENTIONS: All patients were assessed with the GDS-15 and the SADQ-10. RESULTS: The SADQ-10 at a cut-point of 14 out of 30 had a sensitivity of 70% and a specificity of 77% to detect depression. This measure demonstrated good internal consistency but showed only a modest correlation with the GDS-15 (r = 0.40, p < 0.001). CONCLUSION: In the population under study the SADQ-10 did not appear to be a valid measure of depression compared with the GDS and, therefore, may not be suitable for use in patients without significant aphasia.

A comparison of the new executive functioning domains of the CAMCOG-R with existing tests of executive function in elderly stroke survivors.

AIM: to compare the two new executive function tests of the revised Cambridge Cognitive Examination (CAMCOG-R), a bedside measure of cognitive function, with existing neuropsychological assessments of executive function in elderly stroke survivors. METHODS: we assessed 83 stroke survivors at 1 and 3 months post-stroke with the new CAMCOG-R, the Weigl colour form sorting test and Raven's coloured progressive matrices. We assessed functional recovery with the Barthel index and depression with the self-report 15-item geriatric depression scale. We used descriptive statistics, Pearson correlation coefficients, paired t-tests and principal axis factor analyses to interpret the data. RESULTS: the new CAMCOG-R executive functioning tests showed moderate correlation with the Weigl and Raven tests (P<0.01). Improved functional outcome as measured by the Barthel index was significantly associated with higher executive function test scores (P<0.05). Depression was significantly associated with poorer performance on all tasks of executive function (P<0.05). A factor analysis of the scores on all of the neuropsychological tests revealed a single strong factor that accounted for 66% of the variance. The CAMCOG-R and the executive functioning subscales used in this population established sensitivity to change over time. CONCLUSION: although the new executive tests of the CAMCOG-R compared reasonably well with the Weigl and Raven neuropsychological tests, the extra time taken to administer the CAMCOG-R may not be justified. The new CAMCOG-R executive function tests were vulnerable to the effects of depression. Finally, the executive function tests might have provided more of a global measure of cognitive function, raising doubts about their construct validity in our patient population.

The Parkinson's Disease Activities of Daily Living Scale: a new simple and brief subjective measure of disability in Parkinson's disease.

OBJECTIVE: To develop a brief, valid and reliable self-report scale for the assessment of activities of daily living in Parkinson's disease (PD). DESIGN: Self-report questionnaire development. SUBJECTS: One hundred and seventy subjects with a diagnosis of clinically probable PD living in the community. MEASURES: The self-rating scale--Parkinson's Disease Activities of Daily Living Scale (PADLS), Webster Scale, CAMCOG neuropsychological test,15-item Geriatric Depression Scale (GDS-15) and the self-rated Parkinson's Disease Quality of Life (PDQL) questionnaire. METHODS: The PADLS was initially validated and test-retest reliability assessed in a group of PD patients (n = 38). Next a convenience sample of 132 patients was drawn from a community-based PD register. Subjects were invited to complete the PADLS, PDQL, GDS-15, Webster scale and CAMCOG test. RESULTS: The PADLS correlated significantly with increasing age, duration of illness, disease severity, increasing depression, impaired cognition and poorer health-related quality of life. CONCLUSION: The PADLS was found to be a reliable and valid measure of ADL, demonstrating acceptable internal consistency and strong associations with existing measurers of disease severity, depression, cognitive screening and health-related quality of life. The PADLS allows patients to subjectively report the impact that PD has upon daily activities and will complement existing formal clinical measures in PD.

Continuing medical education in Wales: a survey of geriatricians.

OBJECTIVE: to determine what practising geriatricians in Wales do to continue their education; what they would prefer to do; and what their views are on study leave, resources and funding. DESIGN: questionnaire survey. SETTING: the principality of Wales. PARTICIPANTS: hospital-based, career-grade geriatricians. RESULTS: the overall response rate from a total of 56 questionnaires was 87%. More than half [26 (53%)] of the respondents stated they were able to take only half of their study leave entitlement of 10 days a year. Twenty-five (51%) considered this to be due to service commitment. Geriatricians regarded attendance at routine hospital meetings [47 (96%)] and specialist society meetings [45 (92%)], reading books and journals [49 (100%)] and discussion with colleagues [44 (90%)] as their preferred methods of keeping up to date. Most respondents [44 (90%)] said that the resources and funding required to underpin the system of continuing medical education (CME) should be provided by the employing authority. CONCLUSIONS: the many barriers to the continuing education of geriatricians in Wales include service commitments and funding constraints. Geriatricians placed great emphasis on the traditional CME methods such as reading books and journals, attending meetings and conferences and discussion with colleagues and were reluctant to use technology-based educational methods. The results of this study have implications for the way in which geriatricians fulfil CME obligations in the future and provide directions for the planners of CME.

Is the SF-36 health survey questionnaire suitable as a self-report measure of the health status of older adults with Parkinson's disease?

An amended version of the Short Form 36 health survey questionnaire (SF-36), which has been suggested as being more suitable for self-completion in older adults, was evaluated among a group of elderly subjects with Parkinson's disease (PD). In the subjects who were able to fully complete the modified SF-36 unaided, the severity of PD was broadly reflected by low reported levels of functioning and well-being with this measure. However, the modified questionnaire still did not overcome the problem of missing responses from elderly subjects. A total of 24% of respondents missed one or more of the 36 statements and 80% of missing responses were concentrated in the three statements which had been modified. The SF-36 in its original form would need to be combined with a disease-specific measure to adequately evaluate the health status of older adults with PD.

The quality of diagnostic coding in cerebrovascular disease.

We investigated the quality of diagnostic coding in relation to cerebrovascular disease (CVD) in a computerized clinical information system by comparing the codes on the computer printout, obtained from casemix database on 166 patients with a diagnosis of cerebrovascular disease, with the codes allocated by the investigators after examining the case notes. Overall, the diagnostic coding was incorrect in 44 (26%) cases. These inaccuracies included 9 (5%) patients who did not have CVD and 35 (21%) patients who were incorrectly coded as "acute but ill-defined stroke". The inadequacy of information in discharge letters was the main reason for such discrepancies (21 cases). There is a need for adequate education and training of doctors and coding clerks and for a constant dialogue between them if the deficiencies in coding are to be rectified and the value of hospital information system in the audit, costing and health care planning is to be improved.

Percutaneous endoscopic gastrostomy in geriatric patients: attitudes of health care professionals.

This study investigated, by questionnaire, the attitudes of geriatricians, speech therapists, dieticians, and nurses towards feeding by percutaneous endoscopic gastrostomy (PEG). The final response rate from a total of 199 questionnaires sent to this group was 75%. According to 95 (64%) of the respondents, the decision to use PEG feeding was reached by a multidisciplinary team approach and commonly involved carers as well as the patients. The quality of life was the single most important factor influencing this decision. PEG feeding was felt to be indicated in non-dysphagia-related malnutrition by 98 (66%) and in dementia with rejection of oral feeding by 69 (47%) of the respondents. It was felt by 39 (55%) of the nurses and by 32 (42%) of the other professionals that patients with dementia in long-term care who are established on nasogastric feeding should be converted to PEG feeding. This raises several ethical and resource issues.

Stretch reflexes of individual parkinsonian patients studied during changes in clinical rigidity following medication.

Stretch reflexes were elicited in flexor carpi radialis (FCR) of healthy subjects and patients with Parkinson's disease by forcible ramp and hold extensions of the wrist joint. Individual patients were studied off treatment when rigidity was detected clinically at the joint and throughout the clinical response to anti-parkinsonian medication that abolished or reduced their rigidity. In this way the possible effects of inter-subject variability upon the relationship between reflex behaviour and rigidity were eliminated. The long-latency (M2) stretch reflexes of the patient group were increased on average compared to those of healthy subjects. However, in the large majority of individual patients there were no significant correlations between the amplitudes of their M2 or total (short-latency (M1) + M2) reflex activities, recorded off and on treatment, and the accompanying changes in clinically assessed rigidity. These results suggest that parkinsonian rigidity cannot be uniquely attributed to the increased reflex responsiveness measured by the present laboratory techniques. However, the techniques used to test reflex function in our study differed in several respects (e.g., background activity, stretching wave form) from those employed during clinical assessment of rigidity so that the balance of reflex mechanisms may have varied in the two situations. Therefore, these results cannot be taken as definitive evidence against a reflex origin of rigidity.

Relationship between electromyographic activity and clinically assessed rigidity studied at the wrist joint in Parkinson's disease.

The electromyographic (EMG) patterns recorded from wrist muscles during manually applied, repetitive flexion and extension movements of the wrist joint, used for simultaneous clinical assessment of rigidity, were studied in patients with Parkinson's disease and healthy subjects. Recordings were made whilst patients/subjects attempted voluntarily to relax the muscle of the arm whose wrist joint was manipulated. Individual patients were investigated before and at varying times after their routine daily medication as their clinical rigidity underwent associated modulations. It was often possible to induce additional alterations in clinical rigidity by instructing patients to perform an activation or Jendrassik-like manoeuvre (clenching the contralateral fist). In rigid patients, the approximately sinusoidal wrist displacements (60 deg, 1-1.5 Hz) typically elicited pronounced, cyclic modulations of EMG activities in wrist flexors and extensors; increases in EMG activity were phase-locked to the respective periods of muscle stretch. Stretch-related EMG activity reduced or disappeared as rigidity was abolished by drug therapy. The EMG patterns of patients showing cogwheel rigidity featured discrete, phasic bursts superimposed upon more generalized stretch-related increases in activity. In healthy subjects, showing no clinical rigidity, the pronounced cyclic modulations of EMG activity characteristic of rigid patients were absent during similar manually applied wrist displacements. Quantitative EMG measurements for individual patients, made 'on' and 'off' medication and as their rigidity fluctuated, indicated that mild (grade 1) and moderate (grade 2) rigidity was consistently associated with increased stretch-related activity compared with non-rigid conditions. Pair-wise statistical analysis indicated such increases in EMG to be significant. Similarly, the ratios of EMG activities in the stretched versus released muscles were significantly greater for grades 1 and 2 rigidity than in the absence of rigidity. Overall, the present findings support the view that enhancement of stretch reflex activity has a major role in the genesis of parkinsonian rigidity.

Hereditary progressive chorea without dementia.

A family with hereditary non-Huntington's chorea is presented. Transmission was autosomal dominant with variable penetrance. Chorea commenced in childhood and affected predominantly the head, face and upper limbs. Dysarthria appeared later, followed in two family members by elements of an axial dystonia. There was no intellectual impairment. Unlike previously described families, symptoms progressed steadily up to the eighth decade, causing considerable physical disability.